Healthcare Provider Details

I. General information

NPI: 1568442838
Provider Name (Legal Business Name): IVAN GONZALEZ D.P.M
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 11/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18710 LINDEN BLVD
SAINT ALBANS NY
11412-4026
US

IV. Provider business mailing address

351 E 85TH ST 4A
NEW YORK NY
10028-4556
US

V. Phone/Fax

Practice location:
  • Phone: 718-723-1769
  • Fax:
Mailing address:
  • Phone: 212-734-9013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberN005253
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: