Provider Demographics
NPI:1912971367
Name:GONZALEZ, ALFONSO (MD)
Entity type:Individual
Prefix:
First Name:ALFONSO
Middle Name:
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 1:3600 FOREST DR STE 400
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-4057
Mailing Address - Country:US
Mailing Address - Phone:803-779-7316
Mailing Address - Fax:803-343-2538
Practice Address - Street 1:3600 FOREST DR STE 400
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-4057
Practice Address - Country:US
Practice Address - Phone:803-779-7316
Practice Address - Fax:803-343-2538
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17121207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC070017292OtherRAILROAD MEDICARE
SC171217Medicaid
SC171217Medicaid
SCF347477479Medicare ID - Type Unspecified