Provider Demographics
NPI:1427277672
Name:GONZALEZ, KETTY M (MD)
Entity type:Individual
Prefix:DR
First Name:KETTY
Middle Name:M
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1916 N LEG RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-4402
Mailing Address - Country:US
Mailing Address - Phone:706-667-4265
Mailing Address - Fax:706-667-4301
Practice Address - Street 1:1916 N LEG RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-4402
Practice Address - Country:US
Practice Address - Phone:706-667-4265
Practice Address - Fax:706-667-4301
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA0262802083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003137018AMedicaid
GA915044152AMedicaid