Healthcare Provider Details

I. General information

NPI: 1538510508
Provider Name (Legal Business Name): GABRIEL ISAZA GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2016
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 COTTMAN AVE
PHILADELPHIA PA
19111-2434
US

IV. Provider business mailing address

333 COTTMAN AVE
PHILADELPHIA PA
19111-2434
US

V. Phone/Fax

Practice location:
  • Phone: 215-728-2191
  • Fax: 215-214-3992
Mailing address:
  • Phone: 215-728-2191
  • Fax: 215-214-3992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD471112
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: