Provider Demographics
NPI:1003953928
Name:RODOLFO H GONZALEZ MD. PC
Entity Type:Organization
Organization Name:RODOLFO H GONZALEZ MD. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RODOLFO
Authorized Official - Middle Name:HECTOR
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-735-8256
Mailing Address - Street 1:1860 TOWN CENTER DR
Mailing Address - Street 2:SUITE 350
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-5896
Mailing Address - Country:US
Mailing Address - Phone:703-435-8256
Mailing Address - Fax:703-435-3337
Practice Address - Street 1:1860 TOWN CENTER DR
Practice Address - Street 2:SUITE 350
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5896
Practice Address - Country:US
Practice Address - Phone:703-435-8256
Practice Address - Fax:703-435-3337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101222040174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA491547Medicare ID - Type Unspecified
VAI03144Medicare UPIN