Healthcare Provider Details

I. General information

NPI: 1619905163
Provider Name (Legal Business Name): EVELYN GONZALEZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 COOPER PLZ SUITE200
CAMDEN NJ
08103-1438
US

IV. Provider business mailing address

1 FEDERAL ST STE 200
CAMDEN NJ
08103-1088
US

V. Phone/Fax

Practice location:
  • Phone: 856-342-2001
  • Fax: 856-963-2499
Mailing address:
  • Phone: 856-356-4924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number07070
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number07070
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number25MA08873300
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2230-5
Identifier TypeOTHER
Identifier StatePR
Identifier IssuerPROSSAM PROVIDER
# 2
IdentifierSE 2613
Identifier TypeOTHER
Identifier StatePR
Identifier IssuerPALIC PROVIDER NUMBER
# 3
Identifier9260212
Identifier TypeOTHER
Identifier StatePR
Identifier IssuerHUMANA INSURANCE PROVIDER
# 4
Identifier80190 GO
Identifier TypeOTHER
Identifier StatePR
Identifier IssuerTRIPLE-S PROVIDER NUMBER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: