Basic Information
| Provider Information | |||||||||
| NPI: | 1013001999 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JUAN A GONZALEZ MD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3196 KENNEDY BLVD | ||||||||
| Address2: | MAILBOX 16A | ||||||||
| City: | UNION CITY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070872436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2017959080 | ||||||||
| FaxNumber: | 2017959434 | ||||||||
| Practice Location | |||||||||
| Address1: | 3196 KENNEDY BLVD | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | UNION CITY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070872436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2017959080 | ||||||||
| FaxNumber: | 2017959434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 01/04/2012 | ||||||||
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| AuthorizedOfficialLastName: | GONZALEZ | ||||||||
| AuthorizedOfficialFirstName: | JUAN | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2017959080 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 25MA07273600 | NJ | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 25MA4258800 | NJ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0003875 | 05 | NJ | MEDICAID |