Provider Demographics
NPI:1053319699
Name:GONZALEZ, GONZALO A (MD)
Entity Type:Individual
Prefix:DR
First Name:GONZALO
Middle Name:A
Last Name:GONZALEZ
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:PO BOX 2179
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33509-2179
Mailing Address - Country:US
Mailing Address - Phone:813-661-1515
Mailing Address - Fax:813-661-6518
Practice Address - Street 1:4543 S MANHATTAN AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-2330
Practice Address - Country:US
Practice Address - Phone:855-226-6633
Practice Address - Fax:866-285-7068
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2024-02-21
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-06
Provider Licenses
StateLicense IDTaxonomies
FLME62211207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260463901Medicaid
FL110215139OtherRR MEDICARE
FL260463901Medicaid
FL110215139OtherRR MEDICARE