Healthcare Provider Details

I. General information

NPI: 1053989970
Provider Name (Legal Business Name): JOSHUA TYLER JOSEPH GONZALES DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JOSHUA GONZALES DO

II. Dates (important events)

Enumeration Date: 06/16/2021
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 SAINT MARYS DR STE 510
EVANSVILLE IN
47714-0511
US

IV. Provider business mailing address

DEPARTMENT OF GRADUATE MEDICAL EDUCATION 635 BARNHILL DRIVE
INDIANAPOLIS IN
46202
US

V. Phone/Fax

Practice location:
  • Phone: 812-485-4422
  • Fax: 201-603-6684
Mailing address:
  • Phone: 317-274-8282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number11022533A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: