MEDICARE: DR. RUFUS R GONZALES PHD

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	103TC0700X	Clinical Psychologist	071.007450	IL

General Provider Information

NPI Number	:	1548784119
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RUFUS R GONZALES PHD

Provider Business Mailing Address
First Line	:	6238 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-1202
Country	:	US
Telephone Number	:	708-512-4854
Fax Number	:

Provider Business Practice Location Address
First Line	:	6238 N CLARK ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-1202
Country	:	US
Telephone Number	:	708-512-4854
Fax Number	:

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

Provider Enumeration Date	:	07/26/2017
Last Update Date	:	07/21/2022

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