Provider Demographics
NPI:1730737230
Name:GONZALEZ, STEVEN TYLER
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:TYLER
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2229 DEERPATH DR
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-8875
Mailing Address - Country:US
Mailing Address - Phone:847-477-2610
Mailing Address - Fax:
Practice Address - Street 1:555 31ST ST
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1235
Practice Address - Country:US
Practice Address - Phone:630-515-6171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0492255484183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician