Healthcare Provider Details

I. General information

NPI: 1295789154
Provider Name (Legal Business Name): VICTOR CRISTIAN GONZALEZ SA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 12/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3S520 BATAVIA RD
WARRENVILLE IL
60555-3302
US

IV. Provider business mailing address

3S520 BATAVIA RD
WARRENVILLE IL
60555-3302
US

V. Phone/Fax

Practice location:
  • Phone: 630-836-1142
  • Fax: 630-836-1142
Mailing address:
  • Phone: 630-836-1142
  • Fax: 630-836-1142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number05-252
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: