Basic Information
| Provider Information | |||||||||
| NPI: | 1437312147 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | CRISTINA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1140 S KNOXVILLE AVE STE D | ||||||||
| Address2: | |||||||||
| City: | SAINT MARYS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458852609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193001129 | ||||||||
| FaxNumber: | 4193940255 | ||||||||
| Practice Location | |||||||||
| Address1: | 1140 S KNOXVILLE AVE STE A | ||||||||
| Address2: | |||||||||
| City: | SAINT MARYS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458852609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193949959 | ||||||||
| FaxNumber: | 4193940255 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2008 | ||||||||
| LastUpdateDate: | 12/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35.142696 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0455916 | 05 | OH | MEDICAID |