Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 016-005275 | IL |
Y | 222Z00000X | Podiatrist | 016-005275 | IL |
NPI | 1053466797 |
---|---|
Provider Name | Dr. Henry Gonzales |
First Address | Bridgeview, IL 60455-5500 |
Second Address | Chicago, IL 60639-3767 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/01/2007 |
Last Update Date | 27/03/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
016-005275 | LIC POD (01) | IL |
V00094 | (02) | IL |