Provider Demographics
NPI:1316930464
Name:GONZALEZ, GILBERT J (MD)
Entity type:Individual
Prefix:
First Name:GILBERT
Middle Name:J
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 1:1707 MEADOWS LN STE F
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-7201
Mailing Address - Country:US
Mailing Address - Phone:912-537-9481
Mailing Address - Fax:912-537-1380
Practice Address - Street 1:1707 MEADOWS LN STE F
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-7201
Practice Address - Country:US
Practice Address - Phone:912-537-9481
Practice Address - Fax:912-537-1380
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2022-02-01
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
GA026533208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000419273DMedicaid
GAE27969Medicare UPIN
GA511G700892Medicare PIN