Provider Demographics
NPI:1134117526
Name:GONZALEZ, SAMUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
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 1:2495 SHREVEPORT HWY
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-4044
Mailing Address - Country:US
Mailing Address - Phone:318-473-0010
Mailing Address - Fax:
Practice Address - Street 1:2495 SHREVEPORT HWY STE 211
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-4044
Practice Address - Country:US
Practice Address - Phone:318-473-0010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13940208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR20732Medicare ID - Type Unspecified
PRH55680Medicare UPIN