Provider Demographics
NPI:1124087713
Name:GONZALEZ, FAUSTO A (MD)
Entity type:Individual
Prefix:DR
First Name:FAUSTO
Middle Name:A
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 1:13405 ROCKAWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11420-3020
Mailing Address - Country:US
Mailing Address - Phone:718-323-9700
Mailing Address - Fax:718-323-0300
Practice Address - Street 1:13405 ROCKAWAY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11420-3020
Practice Address - Country:US
Practice Address - Phone:718-323-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY229968-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2590034OtherGHI PPO
NY0258138Medicaid
NY286588OtherWELLCARE
NY070SZ1Medicare ID - Type UnspecifiedMEDICARE
NY0258138Medicaid