Healthcare Provider Details

I. General information

NPI: 1669565396
Provider Name (Legal Business Name): JOHANNA JACQUELINE GONZALEZ MEJIA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 NORTH BROAD STREET
ELIZABETH NJ
07208-3398
US

IV. Provider business mailing address

433 NORTH BROAD STREET
ELIZABETH NJ
07208-3398
US

V. Phone/Fax

Practice location:
  • Phone: 908-436-1002
  • Fax: 908-436-1109
Mailing address:
  • Phone: 908-436-1002
  • Fax: 908-436-1109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA06899700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: