MEDICARE: DR. IVAN GONZALEZ D.P.M

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	213E00000X	Podiatrist	N005253	NY

General Provider Information

NPI Number	:	1568442838
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IVAN GONZALEZ D.P.M

Provider Business Mailing Address
First Line	:	351 E 85TH ST
Second Line	:	4A
City	:	NEW YORK
State	:	NY
Zip	:	10028-4556
Country	:	US
Telephone Number	:	212-734-9013
Fax Number	:

Provider Business Practice Location Address
First Line	:	18710 LINDEN BLVD
Second Line	:
City	:	SAINT ALBANS
State	:	NY
Zip	:	11412-4026
Country	:	US
Telephone Number	:	718-723-1769
Fax Number	:

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

Provider Enumeration Date	:	01/20/2006
Last Update Date	:	11/10/2010

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