Provider Demographics
NPI:1104194463
Name:GONZALEZ CAMPBELL, GUSEV (MD)
Entity Type:Individual
Prefix:DR
First Name:GUSEV
Middle Name:
Last Name:GONZALEZ CAMPBELL
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 1:4700 MILLENIA LAKES BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32839-7823
Mailing Address - Country:US
Mailing Address - Phone:407-533-6837
Mailing Address - Fax:407-770-0661
Practice Address - Street 1:14075 TOWN LOOP BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32837-6132
Practice Address - Country:US
Practice Address - Phone:407-438-5858
Practice Address - Fax:407-438-7172
Is Sole Proprietor?:No
Enumeration Date:2011-12-01
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 118595207Q00000X, 207Q00000X
390200000X
PR29866-R390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLO3111OtherMEDICARE
FL013793700Medicaid