Provider Demographics
NPI:1487928875
Name:GONZALES, JAMES EDWARD (CST/CSFA)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:EDWARD
Last Name:GONZALES
Suffix:
Gender:M
Credentials:CST/CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 S PRAIRIE AVE
Mailing Address - Street 2:1302
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3043
Mailing Address - Country:US
Mailing Address - Phone:708-705-3772
Mailing Address - Fax:
Practice Address - Street 1:1515 S PRAIRIE AVE
Practice Address - Street 2:1302
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-3043
Practice Address - Country:US
Practice Address - Phone:708-705-3772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant