Provider Demographics
NPI:1992931034
Name:GONZALO A GONZALEZ MD PA
Entity type:Organization
Organization Name:GONZALO A GONZALEZ MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING/CONTRACTING
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELENA
Authorized Official - Middle Name:BOUSQUET
Authorized Official - Last Name:GALBIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-686-0989
Mailing Address - Street 1:PO BOX 2179
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33509-2179
Mailing Address - Country:US
Mailing Address - Phone:813-633-6550
Mailing Address - Fax:813-633-6551
Practice Address - Street 1:1653 SUN CITY CENTER PLZ
Practice Address - Street 2:SUITE 1002
Practice Address - City:SUN CITY CENTER
Practice Address - State:FL
Practice Address - Zip Code:33573-5394
Practice Address - Country:US
Practice Address - Phone:813-633-6550
Practice Address - Fax:813-633-6551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-03
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0062211207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110215139OtherRR MEDICARE
FL18166OtherBS FL
FL260463901Medicaid
FLF41957Medicare UPIN
FL260463901Medicaid