Provider Demographics
NPI:1891891560
Name:GONZALEZ, JUAN CARLOS (MD)
Entity type:Individual
Prefix:DR
First Name:JUAN
Middle Name:CARLOS
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 1:1107 MEMORIAL DR STE 102
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-8662
Mailing Address - Country:US
Mailing Address - Phone:706-275-6121
Mailing Address - Fax:706-275-0521
Practice Address - Street 1:1107 MEMORIAL DR STE 102
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-8662
Practice Address - Country:US
Practice Address - Phone:706-275-6121
Practice Address - Fax:706-275-0521
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA068737174400000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1072595OtherWELLCARE
GAP01332068OtherRR MEDICARE
GA01934817OtherAMERIGROUP
GA512581223FMedicaid
GA01934817OtherAMERIGROUP