Basic Information
| Provider Information | |||||||||
| NPI: | 1912974957 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | EULOGIO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27 PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | MONTVALE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076452216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187164400 | ||||||||
| FaxNumber: | 7182287471 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 W BURNSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104534015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187164400 | ||||||||
| FaxNumber: | 7182287471 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 03/14/2012 | ||||||||
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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 | 207W00000X | 176363 | NY | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 1189853 | 05 | NY | MEDICAID |