Provider Demographics
NPI:1154358141
Name:GONZALEZ, ARIEL J
Entity type:Individual
Prefix:MR
First Name:ARIEL
Middle Name:J
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:PO BOX 1677
Mailing Address - Street 2:3307 W COMMERCIAL DR
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959
Mailing Address - Country:US
Mailing Address - Phone:618-998-1263
Mailing Address - Fax:618-998-1265
Practice Address - Street 1:3307 W COMMERCIAL DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959
Practice Address - Country:US
Practice Address - Phone:618-998-1263
Practice Address - Fax:618-998-1265
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361072912207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0361072912Medicaid
H83602Medicare UPIN
ILK14380Medicare ID - Type Unspecified