Healthcare Provider Details

I. General information

NPI: 1649614520
Provider Name (Legal Business Name): MARK GONZALEZ ETTEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2013
Last Update Date: 06/30/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVENUE UNIVERSITY OF ROCHESTER MEDICAL CENTER,
ROCHESTER NY
14642-0001
US

IV. Provider business mailing address

601 ELMWOOD AVENUE, BOX 626 URMC
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-3191
  • Fax: 585-273-3637
Mailing address:
  • Phone: 585-275-3191
  • Fax: 585-273-3637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number4301111405
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number293012
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number293012
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: