Healthcare Provider Details

I. General information

NPI: 1902102734
Provider Name (Legal Business Name): TRAVELING DOC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2011
Last Update Date: 01/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 S CICERO AVE
CICERO IL
60804-2545
US

IV. Provider business mailing address

1904 S CICERO AVE
CICERO IL
60804-2545
US

V. Phone/Fax

Practice location:
  • Phone: 855-484-7362
  • Fax: 708-863-7213
Mailing address:
  • Phone: 855-484-7362
  • Fax: 708-863-7213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number036.127046
License Number StateIL

VIII. Authorized Official

Name: DR. CARLOS GONZALEZ JR.
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 561-624-5347