Basic Information
| Provider Information | |||||||||
| NPI: | 1821070806 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ-MARTINEZ | ||||||||
| FirstName: | ERNESTO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9142 | ||||||||
| Address2: | MASS GENERAL PHYSICIAN ORGANIZATION | ||||||||
| City: | CHARLESTOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021299142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177262914 | ||||||||
| FaxNumber: | 6177267768 | ||||||||
| Practice Location | |||||||||
| Address1: | 50 STANIFORD ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021142517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177262914 | ||||||||
| FaxNumber: | 6177267768 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2005 | ||||||||
| LastUpdateDate: | 08/01/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 40589 | MA | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 040589 | 01 | MA | TUFTS HEALTH PLAN | OTHER | M09515 | 01 | MA | BCBS MA | OTHER | 2053586 | 05 | MA | MEDICAID |