Basic Information
| Provider Information | |||||||||
| NPI: | 1306864913 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | E | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4755 SUMMERLIN RD | ||||||||
| Address2: | SUITE 8 | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339191073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392755339 | ||||||||
| FaxNumber: | 2392755592 | ||||||||
| Practice Location | |||||||||
| Address1: | 4755 SUMMERLIN RD | ||||||||
| Address2: | SUITE 8 | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339191073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392755339 | ||||||||
| FaxNumber: | 2392755592 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 01/05/2011 | ||||||||
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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 | 207Q00000X | ME25089 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036797400 | 05 | FL | MEDICAID |