Provider Demographics
NPI:1427098490
Name:GONZALEZ, ERNEST
Entity type:Individual
Prefix:
First Name:ERNEST
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 ZEAGLER DR
Mailing Address - Street 2:SUITE 600
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177
Mailing Address - Country:US
Mailing Address - Phone:386-328-9484
Mailing Address - Fax:386-328-6569
Practice Address - Street 1:800 ZEAGLER DR
Practice Address - Street 2:SUITE 600
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-3867
Practice Address - Country:US
Practice Address - Phone:386-328-9484
Practice Address - Fax:386-328-6569
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME38861208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL066796000Medicaid
E18236Medicare UPIN