Provider Demographics
NPI:1730136060
Name:GONZALEZ, RICHARD P (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:P
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 1:2160 S 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:708-216-9000
Mailing Address - Fax:708-216-9000
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-216-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360832602086S0102X, 2086S0102X
AL222502086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1151181Medicaid
FL255987100Medicaid
AL51044493OtherBLUE CROSS
AL17-10433OtherUNITED HEALTH CARE
AL51592788OtherBCBS - 2451 FILLINGIM
MS00120450Medicaid
AL000044493Medicaid
AL020042466OtherRAILROAD MEDICARE PTAN
AL51593901OtherBCBS - 575 STANTON ROAD
AL51044493OtherBLUE CROSS
AL020042466OtherRAILROAD MEDICARE PTAN