Basic Information
| Provider Information | |||||||||
| NPI: | 1033272331 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALES | ||||||||
| FirstName: | EUSEBIO | ||||||||
| MiddleName: | P. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 RINGLING BLVD | ||||||||
| Address2: | |||||||||
| City: | SARASOTA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342376102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9418612900 | ||||||||
| FaxNumber: | 9418612719 | ||||||||
| Practice Location | |||||||||
| Address1: | 6950 OUTREACH WAY | ||||||||
| Address2: | |||||||||
| City: | NORTH PORT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342873405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9418612900 | ||||||||
| FaxNumber: | 9418612719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 10/09/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | D0012712 | MD | N | Other Service Providers | Specialist | 174400000X | ME92088 | FL | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 004188400 | 05 | FL | MEDICAID | 35306201 | 01 | MD | CAREFIRST BCBS | OTHER |