MEDICARE: DR. LENORE EVANS GONZALEZ M.D.

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	2080P0207X	Pediatric Hematology & Oncology Physician		IL

General Provider Information

NPI Number	:	1639395304
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LENORE EVANS GONZALEZ M.D.

Provider Business Mailing Address
First Line	:	236 S 5TH ST
Second Line	:	APT C
City	:	SPRINGFIELD
State	:	IL
Zip	:	62701-1431
Country	:	US
Telephone Number	:	312-259-7986
Fax Number	:

Provider Business Practice Location Address
First Line	:	236 S 5TH ST
Second Line	:	APT C
City	:	SPRINGFIELD
State	:	IL
Zip	:	62701-1431
Country	:	US
Telephone Number	:	312-259-7986
Fax Number	:

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

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	03/07/2023

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