Basic Information
| Provider Information | |||||||||
| NPI: | 1639150949 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONCALVES | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 120 MINEOLA BLVD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115014073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166634400 | ||||||||
| FaxNumber: | 5166634404 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 MINEOLA BLVD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | MINEOLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115014073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166634400 | ||||||||
| FaxNumber: | 5166634404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 10/27/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 201051-1 | NY | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
No ID Information.