Provider Demographics
NPI:1386723492
Name:GILBERT J. GONZALEZ, M.D., LLC
Entity type:Organization
Organization Name:GILBERT J. GONZALEZ, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:HOOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-537-9481
Mailing Address - Street 1:303 HARRIS INDUSTRIAL BLVD.
Mailing Address - Street 2:SUITE 5
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474
Mailing Address - Country:US
Mailing Address - Phone:912-537-9481
Mailing Address - Fax:912-537-1380
Practice Address - Street 1:303 HARRIS INDUSTRIAL BLVD.
Practice Address - Street 2:SUITE 5
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474
Practice Address - Country:US
Practice Address - Phone:912-537-9481
Practice Address - Fax:912-537-1380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA026533208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00419273DMedicaid
GA34BDDPFMedicare ID - Type Unspecified
GA00419273DMedicaid