Healthcare Provider Details

I. General information

NPI: 1013394345
Provider Name (Legal Business Name): PEDRO JOSE GONZALEZ JIMENEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2015
Last Update Date: 02/03/2026
Certification Date: 02/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

789 HOWARD AVE YNHH PEDIATRICS
NEW HAVEN CT
06519-1304
US

IV. Provider business mailing address

789 HOWARD AVE YNHH PEDIATRICS
NEW HAVEN CT
06519-1304
US

V. Phone/Fax

Practice location:
  • Phone: 203-688-5555
  • Fax:
Mailing address:
  • Phone: 203-688-5555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number85352
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberW1421
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number804073536
License Number StatePR
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: