Provider Demographics
NPI:1396739488
Name:GONZALEZ, JAY M (DO)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:M
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 W 9TH AVE
Mailing Address - Street 2:STE 230
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-7247
Mailing Address - Country:US
Mailing Address - Phone:920-223-0220
Mailing Address - Fax:
Practice Address - Street 1:2700 W 9TH AVE
Practice Address - Street 2:STE 230
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7247
Practice Address - Country:US
Practice Address - Phone:920-223-0220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46930207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43514100Medicaid
I13058Medicare UPIN
WI047571018Medicare PIN