Healthcare Provider Details

I. General information

NPI: 1114306537
Provider Name (Legal Business Name): JAIME GONZALEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2015
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1969 WEST HART RD
BELOIT WI
53511-2283
US

IV. Provider business mailing address

1969 WEST HART RD
BELOIT WI
53511-2283
US

V. Phone/Fax

Practice location:
  • Phone: 608-364-5011
  • Fax: 608-364-5452
Mailing address:
  • Phone: 608-364-5011
  • Fax: 608-364-5452

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 StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number73854
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number73854-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: