Provider Demographics
NPI:1902223209
Name:GONZALEZ, JAVIER VIDAL (MD)
Entity Type:Individual
Prefix:DR
First Name:JAVIER
Middle Name:VIDAL
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JAVIER
Other - Middle Name:VIDAL
Other - Last Name:GONZALEZ-COTTO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:660 N WESTMORELAND RD
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1659
Mailing Address - Country:US
Mailing Address - Phone:847-234-5600
Mailing Address - Fax:
Practice Address - Street 1:660 N WESTMORELAND RD
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1659
Practice Address - Country:US
Practice Address - Phone:845-234-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036141353207R00000X
390200000X
IL036141352208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program