Healthcare Provider Details

I. General information

NPI: 1790878148
Provider Name (Legal Business Name): PETER G. GONZALEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2006
Last Update Date: 05/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 ROUTE 34 SUITE D
MANASQUAN NJ
08736-1444
US

IV. Provider business mailing address

2315 ROUTE 34 SUITE D
MANASQUAN NJ
08736-1444
US

V. Phone/Fax

Practice location:
  • Phone: 732-974-0404
  • Fax: 732-974-2653
Mailing address:
  • Phone: 732-974-0404
  • Fax: 732-974-2653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number0101246363
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number0101246363
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: