Provider Demographics
NPI:1053379453
Name:GONZALES, NIKOLAI Y (MD)
Entity type:Individual
Prefix:
First Name:NIKOLAI
Middle Name:Y
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 1:56 KING ST
Mailing Address - Street 2:
Mailing Address - City:SWAMPSCOTT
Mailing Address - State:MA
Mailing Address - Zip Code:01907-2131
Mailing Address - Country:US
Mailing Address - Phone:978-354-3384
Mailing Address - Fax:
Practice Address - Street 1:81 HIGHLAND AVE
Practice Address - Street 2:ANESTHESIA ASSOC OF SALEM INC
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970
Practice Address - Country:US
Practice Address - Phone:978-354-3384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA224717207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2116154Medicaid
MAA38692Medicare PIN
I33163Medicare UPIN
MAA3869202Medicare PIN