Basic Information
| Provider Information | |||||||||
| NPI: | 1669513909 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | CARLOS | ||||||||
| MiddleName: | ALFONSO | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 345 HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | CHESHIRE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064102550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032723055 | ||||||||
| FaxNumber: | 2032723303 | ||||||||
| Practice Location | |||||||||
| Address1: | 317 NORTH MAIN STREET | ||||||||
| Address2: | C/O CCGC | ||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606432101 | ||||||||
| FaxNumber: | 8606451470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 10/12/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 029950 | CT | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | 029950 | CT | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
No ID Information.