Basic Information
| Provider Information | |||||||||
| NPI: | 1013394345 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ JIMENEZ | ||||||||
| FirstName: | PEDRO | ||||||||
| MiddleName: | JOSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 789 HOWARD AVE | ||||||||
| Address2: | YNHH PEDIATRICS | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036885555 | ||||||||
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| Practice Location | |||||||||
| Address1: | 789 HOWARD AVE | ||||||||
| Address2: | YNHH PEDIATRICS | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036885555 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2015 | ||||||||
| LastUpdateDate: | 05/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | 804073536 | PR | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 85352 | GA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.