Provider Demographics
NPI:1033272331
Name:GONZALES, EUSEBIO P (MD)
Entity Type:Individual
Prefix:DR
First Name:EUSEBIO
Middle Name:P
Last Name:GONZALES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 RINGLING BLVD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34237-6102
Mailing Address - Country:US
Mailing Address - Phone:941-861-2900
Mailing Address - Fax:941-861-2719
Practice Address - Street 1:6950 OUTREACH WAY
Practice Address - Street 2:
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34287-3405
Practice Address - Country:US
Practice Address - Phone:941-861-2900
Practice Address - Fax:941-861-2719
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0012712174400000X
FLME92088174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004188400Medicaid
MD35306201OtherCAREFIRST BCBS
FL004188400Medicaid