MEDICARE: MR. JORGE A GONZALEZ CPO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1744P3200X	Prosthetics Case Management	1744P3200X	NY

General Provider Information

NPI Number	:	1205962933
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JORGE A GONZALEZ CPO

Provider Business Mailing Address
First Line	:	63 MAPLE DR W
Second Line	:
City	:	NEW HYDE PARK
State	:	NY
Zip	:	11040-3154
Country	:	US
Telephone Number	:	516-270-3781
Fax Number	:

Provider Business Practice Location Address
First Line	:	1402 CASTLE HILL AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10462-4809
Country	:	US
Telephone Number	:	718-824-3595
Fax Number	:	718-824-4404

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/26/2007
Last Update Date	:	07/08/2007

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