MEDICARE: DR. HENRY GONZALES D.P.M.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist	016-005275	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	016-005275	OTHER	IL	LIC POD

General Provider Information

NPI Number	:	1053466797
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HENRY GONZALES D.P.M.

Provider Business Mailing Address
First Line	:	10225A CAMDEN LN
Second Line	:
City	:	BRIDGEVIEW
State	:	IL
Zip	:	60455-5500
Country	:	US
Telephone Number	:	708-790-1303
Fax Number	:

Provider Business Practice Location Address
First Line	:	2008 N PULASKI RD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60639-3767
Country	:	US
Telephone Number	:	773-968-6942
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2007
Last Update Date	:	03/27/2017

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