Healthcare Provider Details

I. General information

NPI: 1346879095
Provider Name (Legal Business Name): ELISA GLUBOK GONZALEZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2020
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 CASS AVE
WOONSOCKET RI
02895-4731
US

IV. Provider business mailing address

450 CLINTON ST
WOONSOCKET RI
02895-3207
US

V. Phone/Fax

Practice location:
  • Phone: 401-769-4100
  • Fax:
Mailing address:
  • Phone: 401-767-4100
  • Fax: 401-235-6895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD19377
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA184272
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number04-51422
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: