Basic Information
| Provider Information | |||||||||
| NPI: | 1588683585 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | DANIEL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 444 CLINCHFIELD STREET | ||||||||
| Address2: | SUITE 2900 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232456101 | ||||||||
| FaxNumber: | 4232452396 | ||||||||
| Practice Location | |||||||||
| Address1: | 444 CLINCHFIELD STREET | ||||||||
| Address2: | SUITE 2900 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232456101 | ||||||||
| FaxNumber: | 4232452396 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 03/10/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | MD19962 | TN | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 208600000X | MD19962 | TN | Y | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | MD19962 | TN | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 265295 | 01 | VA | ANTHEM BCBS VIRGINIA | OTHER | 20043969 | 01 | TN | RAILROAD MEDICARE | OTHER | 3046049 | 05 | TN | MEDICAID | 4656188 | 01 | AETNA | OTHER | 3130863 | 01 | TN | BCBS TENNESSEE | OTHER | 7311095 | 01 | VA | VIRGINIA MEDICAID | OTHER |