Provider Demographics
NPI:1073596813
Name:GONZALEZ, MANUEL F (MD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:F
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 1:115 N SUMTER ST
Mailing Address - Street 2:SUITE 305
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-4972
Mailing Address - Country:US
Mailing Address - Phone:803-934-8348
Mailing Address - Fax:803-934-8349
Practice Address - Street 1:115 N SUMTER ST
Practice Address - Street 2:SUITE 305
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4972
Practice Address - Country:US
Practice Address - Phone:803-934-8348
Practice Address - Fax:803-934-8349
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9747174400000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4045Medicaid
SCGP3381Medicaid
SCGP4045Medicaid
SCB87826Medicare UPIN