Healthcare Provider Details

I. General information

NPI: 1083445563
Provider Name (Legal Business Name): EDWARD GONZALES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2024
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 36TH ST SW
WYOMING MI
49509-3587
US

IV. Provider business mailing address

950 36TH ST SW
WYOMING MI
49509-3587
US

V. Phone/Fax

Practice location:
  • Phone: 616-336-8800
  • Fax: 616-320-0406
Mailing address:
  • Phone: 616-336-8800
  • Fax: 616-320-0406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: