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General NPI Number Information
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NPI Number | 1902102734
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Entity Type | Organization
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Legal Business Name | TRAVELING DOC INC.
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Dates
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Enumeration Date | 01/26/2011
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Last Update Date | 01/26/2011
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Provider Practice Location Address
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Address Line | 1904 S CICERO AVE
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City | CICERO
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State | IL
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Zip | 60804-2545
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Country | US
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Telephone | 855-484-7362
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Fax | 708-863-7213
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Provider Business Mailing Address
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Address Line | 1904 S CICERO AVE
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City | CICERO
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State | IL
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Zip | 60804-2545
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Country | US
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Telephone | 855-484-7362
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Fax | 708-863-7213
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | DR. CARLOS GONZALEZ JR.
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Credential | M.D.
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Telephone | 561-624-5347
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 036.127046
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License Number State | IL
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