Provider Demographics
NPI:1316948367
Name:GONZALEZ, GUILLERMO (MD)
Entity type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:
Last Name:GONZALEZ
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:PO BOX 3021
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02741-3021
Mailing Address - Country:US
Mailing Address - Phone:508-990-4963
Mailing Address - Fax:508-990-4964
Practice Address - Street 1:196 UNION ST
Practice Address - Street 2:
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02740-5942
Practice Address - Country:US
Practice Address - Phone:508-990-4963
Practice Address - Fax:508-990-4964
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA597032084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1003490OtherBEACON
MA110055741AMedicaid
MA3137988Medicaid
MA110055741AMedicaid