Provider Demographics
NPI:1053365932
Name:GONZALEZ, JORGE A (MD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:A
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1125 WILLOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:SCHERERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46375-1488
Mailing Address - Country:US
Mailing Address - Phone:219-218-8567
Mailing Address - Fax:888-224-1384
Practice Address - Street 1:1125 WILLOWBROOK DR
Practice Address - Street 2:
Practice Address - City:SCHERERVILLE
Practice Address - State:IN
Practice Address - Zip Code:46375-1488
Practice Address - Country:US
Practice Address - Phone:219-218-8567
Practice Address - Fax:888-224-1384
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01049228A207L00000X
TXP2119207L00000X
NC2017-01463207N00000X
VA0101262432207L00000X
IL036100122207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000280445OtherANTHEM
1053365932OtherNPI
IL200411250AMedicaid
IL336-060457OtherILLINOIS STATE
1053365932OtherNPI