Provider Demographics
NPI:1174968945
Name:GONZALEZ, JEFFREY MICHAEL
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MICHAEL
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 1:2868 COUNTY ROUTE 10
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12496-1639
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2868 COUNTY ROUTE 10
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:NY
Practice Address - Zip Code:12496-1639
Practice Address - Country:US
Practice Address - Phone:407-625-6535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-06
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS37322183500000X
NY057624183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist