1689610701 NPI number — MR. LORENZO AZCARATE GONZALES PT

Table of content: MR. LORENZO AZCARATE GONZALES PT (NPI 1689610701)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689610701 NPI number — MR. LORENZO AZCARATE GONZALES PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALES
Provider First Name:
LORENZO
Provider Middle Name:
AZCARATE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689610701
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/29/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5 REILLY CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
METUCHEN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08840-2917
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-549-3534
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
760 AMBOY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDISON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08837-3224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-661-1121
Provider Business Practice Location Address Fax Number:
732-661-1151
Provider Enumeration Date:
06/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  40QA01056700 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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