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General NPI Number Information
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NPI Number | 1568565737
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Entity Type | Individual
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Provider Name | MARIO GONZALEZ D.O.
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Gender | Male
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Dates
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Enumeration Date | 09/06/2006
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Last Update Date | 10/21/2019
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Provider Practice Location Address
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Address Line | 111 S 11TH ST STE G8490
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City | PHILADELPHIA
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State | PA
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Zip | 19107
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Country | US
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Telephone | 215-955-6161
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Fax |
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Provider Business Mailing Address
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Address Line | 111 S 11TH ST STE G8490
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City | PHILADELPHIA
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State | PA
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Zip | 19107-4824
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Country | US
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Telephone | 215-955-1120
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Fax | 215-255-3577
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | OS013709
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License Number State | PA
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