Provider Demographics
NPI:1043541162
Name:POTENCIANO GONZALES MD PA
Entity Type:Organization
Organization Name:POTENCIANO GONZALES MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:POTENCIANO
Authorized Official - Middle Name:DIVINO
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:386-668-8559
Mailing Address - Street 1:62 SPRING VISTA DR STE 101
Mailing Address - Street 2:
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-1812
Mailing Address - Country:US
Mailing Address - Phone:386-668-8559
Mailing Address - Fax:
Practice Address - Street 1:62 SPRING VISTA DR STE 100
Practice Address - Street 2:
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-1812
Practice Address - Country:US
Practice Address - Phone:386-668-8559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-29
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty