Provider Demographics
NPI:1780095752
Name:GONZALES, IAN (MD)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:GONZALES
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 1:235 WEALTHY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5247
Mailing Address - Country:US
Mailing Address - Phone:616-840-7135
Mailing Address - Fax:616-840-9690
Practice Address - Street 1:700 COOPER AVE STE 1100
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-5383
Practice Address - Country:US
Practice Address - Phone:989-583-2720
Practice Address - Fax:989-583-1888
Is Sole Proprietor?:No
Enumeration Date:2014-05-13
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301105287208100000X
MIL241021208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation