Basic Information
| Provider Information | |||||||||
| NPI: | 1982908760 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | E. GONZALEZ MD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4755 SUMMERLIN RD STE 8 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339191073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392755339 | ||||||||
| FaxNumber: | 2392755592 | ||||||||
| Practice Location | |||||||||
| Address1: | 4755 SUMMERLIN RD STE 8 | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339191073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2392755339 | ||||||||
| FaxNumber: | 2392755592 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2011 | ||||||||
| LastUpdateDate: | 01/07/2011 | ||||||||
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| AuthorizedOfficialLastName: | GONZALEZ | ||||||||
| AuthorizedOfficialFirstName: | E | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 2392755339 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD PA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 036797400 | 05 | FL | MEDICAID |