Provider Demographics
NPI:1023114246
Name:GONZALEZ, GUILLERMO EDUARDO (DC)
Entity type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:EDUARDO
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2061
Mailing Address - Street 2:1105 4TH AVENUE
Mailing Address - City:WOODRUFF
Mailing Address - State:WI
Mailing Address - Zip Code:54568-2061
Mailing Address - Country:US
Mailing Address - Phone:715-356-1606
Mailing Address - Fax:715-356-2170
Practice Address - Street 1:1105 4TH AVENUE
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:WI
Practice Address - Zip Code:54568-2061
Practice Address - Country:US
Practice Address - Phone:715-356-1606
Practice Address - Fax:715-356-2170
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3390-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38901900Medicaid
WI38901900Medicaid
WI000675290Medicare ID - Type Unspecified
WI38901900Medicaid