Basic Information
Provider Information | |||||||||
NPI: | 1760594303 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GONZALEZ | ||||||||
FirstName: | FROYLAN | ||||||||
MiddleName: | CLAUDIO | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1930 BRANNAN RD | ||||||||
Address2: |   | ||||||||
City: | MCDONOUGH | ||||||||
State: | GA | ||||||||
PostalCode: | 302534310 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6782844040 | ||||||||
FaxNumber: | 3782844076 | ||||||||
Practice Location | |||||||||
Address1: | 790 CHURCH ST NE | ||||||||
Address2: | SUITE 430 | ||||||||
City: | MARIETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300607282 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7704299100 | ||||||||
FaxNumber: | 7704291391 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2006 | ||||||||
LastUpdateDate: | 08/11/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/11/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 2006024406 | MO | N |   | Allopathic & Osteopathic Physicians | Urology |   | 208800000X | 061078 | GA | Y |   | Allopathic & Osteopathic Physicians | Urology |   |
ID Information
ID | Type | State | Issuer | Description | 201026705 | 05 | MO |   | MEDICAID | BG9958563 | 01 | IL | DEA | OTHER | 505232288A | 05 | GA |   | MEDICAID |