Healthcare Provider Details

I. General information

NPI: 1497853840
Provider Name (Legal Business Name): JENNIFER GONZALEZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 S JERSEY AVE STE 1
EAST SETAUKET NY
11733-2065
US

IV. Provider business mailing address

1500 ROUTE 112 BLDG 4
PORT JEFFERSON STATION NY
11776-8055
US

V. Phone/Fax

Practice location:
  • Phone: 631-751-3000
  • Fax: 631-751-0506
Mailing address:
  • Phone: 631-751-3000
  • Fax: 631-751-0506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number224617
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: