Provider Demographics
NPI:1609924174
Name:GONZALEZ, JORGE TIRADOR (MD)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:TIRADOR
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 1:601 W CHISHOLM ST
Mailing Address - Street 2:P.O. BOX 296
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707-2426
Mailing Address - Country:US
Mailing Address - Phone:989-356-9880
Mailing Address - Fax:989-356-9890
Practice Address - Street 1:601 W CHISHOLM ST
Practice Address - Street 2:
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-2426
Practice Address - Country:US
Practice Address - Phone:989-356-9880
Practice Address - Fax:989-356-9890
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010662902084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1300400361OtherBLUE CROSS BLUE SHIELD MI
MI130017016OtherRAILROAD MEDICARE
MI1004394OtherCOUNTY HEALTH PLAN
MI103237981Medicaid
MI1300400361OtherBLUE CROSS BLUE SHIELD MI
MI1004394OtherCOUNTY HEALTH PLAN