Basic Information
| Provider Information | |||||||||
| NPI: | 1104016633 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KNUDSON GONZALEZ | ||||||||
| FirstName: | DEBORAH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 809 S FREMONT AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336062814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8134091729 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3515 E FLETCHER AVE # MDC14 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336134706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139748900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2007 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | ME131782 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 021751700 | 05 | FL | MEDICAID | T280A | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER |