Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | 228391 | MA |
N | 111NI0900X | Internist | 228391 | MA |
Y | 207R00000X | Internist | MD436675 | PA |
Y | 111NI0900X | Internist | MD436675 | PA |
NPI | 1003073685 |
---|---|
Provider Name | Dr. Jed David Gonzalo |
First Address | Hershey, PA 17033-0858 |
Second Address | Hershey, PA 17033-2360 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/05/2008 |
Last Update Date | 17/01/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1023683370003 | (05) | PA |