Healthcare Provider Details

I. General information

NPI: 1164856704
Provider Name (Legal Business Name): GRANT WILSON GONZALEZ D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2013
Last Update Date: 03/07/2023
Certification Date: 04/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2921 MONTVALE DR
SPRINGFIELD IL
62704-5359
US

IV. Provider business mailing address

2921 MONTVALE DR
SPRINGFIELD IL
62704-5359
US

V. Phone/Fax

Practice location:
  • Phone: 217-787-2700
  • Fax: 217-787-2715
Mailing address:
  • Phone: 217-787-2700
  • Fax: 217-787-2715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD001231
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016005651
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: