Provider Demographics
NPI:1154346153
Name:GONZALEZ, LEOPOLDO B (MD)
Entity type:Individual
Prefix:
First Name:LEOPOLDO
Middle Name:B
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 1:301 HEALTH PARK BLVD
Mailing Address - Street 2:ANDERSON GIBBS BLDG., SUITE 221
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5793
Mailing Address - Country:US
Mailing Address - Phone:904-824-4277
Mailing Address - Fax:904-824-4490
Practice Address - Street 1:301 HEALTH PARK BLVD
Practice Address - Street 2:ANDERSON GIBBS BLDG., SUITE 221
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5793
Practice Address - Country:US
Practice Address - Phone:904-824-4277
Practice Address - Fax:904-824-4490
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0022097174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL054187700Medicaid
FLD53375Medicare UPIN