Provider Demographics
NPI:1902896103
Name:GONZALEZ, JOSE A (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:A
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 E 14 MILE RD
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-7244
Mailing Address - Country:US
Mailing Address - Phone:248-642-4474
Mailing Address - Fax:248-642-4499
Practice Address - Street 1:1915 E 14 MILE RD
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-7244
Practice Address - Country:US
Practice Address - Phone:248-642-4474
Practice Address - Fax:248-642-4499
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301038459208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
16391278341Medicare ID - Type Unspecified
B48966Medicare UPIN