Healthcare Provider Details

I. General information

NPI: 1104823228
Provider Name (Legal Business Name): ARMAND A GONZALZLES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 04/28/2011
Certification Date:
Deactivation Date: 03/20/2006
Reactivation Date: 04/06/2006

III. Provider practice location address

2045 W. WASHINGTON BLVD M/C 698
CHICAGO IL
60612-2428
US

IV. Provider business mailing address

2045 W. WASHINGTON BLVD M/C 698
CHICAGO IL
60612-2428
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-2000
  • Fax: 312-413-7812
Mailing address:
  • Phone: 312-996-2000
  • Fax: 312-413-7812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036052969
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: