=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669648572
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN W. GONZALEZ, MD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2008
-----------------------------------------------------
Last Update Date | 04/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 E HOSPITAL LN SUITE 104
-----------------------------------------------------
City | TERRE HAUTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47802-4230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-232-5518
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 501 E HOSPITAL LN SUITE 104
-----------------------------------------------------
City | TERRE HAUTE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47802-4230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-232-5518
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOHN WINSTON GONZALEZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 812-232-5518
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 01052463
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------