Provider Demographics
NPI:1568256931
Name:GONZALEZ, SERGIO R (HIS)
Entity type:Individual
Prefix:MR
First Name:SERGIO
Middle Name:R
Last Name:GONZALEZ
Suffix:
Gender:
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1841 N ELMER ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-3203
Mailing Address - Country:US
Mailing Address - Phone:574-367-2700
Mailing Address - Fax:
Practice Address - Street 1:1841 N ELMER ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-3203
Practice Address - Country:US
Practice Address - Phone:574-367-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-08
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN17001630A237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist