Provider Demographics
NPI:1407045289
Name:GONZALO T FLORIDO MD SC
Entity type:Organization
Organization Name:GONZALO T FLORIDO MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GONZALO
Authorized Official - Middle Name:T
Authorized Official - Last Name:FLORIDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-432-6744
Mailing Address - Street 1:714 S 10TH ST
Mailing Address - Street 2:
Mailing Address - City:WATSEKA
Mailing Address - State:IL
Mailing Address - Zip Code:60970-1827
Mailing Address - Country:US
Mailing Address - Phone:815-432-6744
Mailing Address - Fax:
Practice Address - Street 1:714 S 10TH ST
Practice Address - Street 2:
Practice Address - City:WATSEKA
Practice Address - State:IL
Practice Address - Zip Code:60970-1827
Practice Address - Country:US
Practice Address - Phone:815-432-6744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-074510207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208156Medicare Oscar/Certification
K03465Medicare PIN
F48712Medicare UPIN