Healthcare Provider Details

I. General information

NPI: 1629516547
Provider Name (Legal Business Name): WILLY GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2017
Last Update Date: 04/19/2024
Certification Date: 04/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WHITE PLAINS RD FL 4
TARRYTOWN NY
10591-5838
US

IV. Provider business mailing address

833 CHESTNUT ST STE 520
PHILADELPHIA PA
19107-4430
US

V. Phone/Fax

Practice location:
  • Phone: 888-636-7840
  • Fax: 267-479-1321
Mailing address:
  • Phone: 609-677-7003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number25MB11472800
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number316950
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: