Provider Demographics
NPI:1124225321
Name:GONZALES, HENRY AUGUSTINE (MD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:AUGUSTINE
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 1:2376 CYPRESS CIR STE 203
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-8994
Mailing Address - Country:US
Mailing Address - Phone:843-347-4600
Mailing Address - Fax:843-347-6495
Practice Address - Street 1:2376 CYPRESS CIR STE 203
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8994
Practice Address - Country:US
Practice Address - Phone:843-347-4600
Practice Address - Fax:843-347-6495
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26533207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCA46996Medicare UPIN