Healthcare Provider Details

I. General information

NPI: 1619941978
Provider Name (Legal Business Name): LYDIA GONZALEZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 02/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 WEST BURNSIDE AVE
BRONX NY
10453-4015
US

IV. Provider business mailing address

85 W BURNSIDE AVE
BRONX NY
10453-4015
US

V. Phone/Fax

Practice location:
  • Phone: 718-716-4400
  • Fax: 718-228-7471
Mailing address:
  • Phone: 718-716-4400
  • Fax: 718-228-7471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number167781
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: