Healthcare Provider Details

I. General information

NPI: 1780854745
Provider Name (Legal Business Name): SARA C GONZALEZ D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2008
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

IV. Provider business mailing address

7 PARSONS LNDG
ISLIP NY
11751-4132
US

V. Phone/Fax

Practice location:
  • Phone: 617-355-6000
  • Fax:
Mailing address:
  • Phone: 631-766-3463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number248380
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: