Provider Demographics
NPI:1275601437
Name:GONWA, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GONWA
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 1:68 MONTEREY POINT DR
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418
Mailing Address - Country:US
Mailing Address - Phone:561-670-5215
Mailing Address - Fax:
Practice Address - Street 1:1500 N DIXIE HWAY
Practice Address - Street 2:STE 306
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401
Practice Address - Country:US
Practice Address - Phone:561-837-4834
Practice Address - Fax:561-837-2225
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME643112085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000545011OtherANTHEM BCBS
KY7100037330Medicaid
FL378003100Medicaid
BG3721114OtherDEA
KYP00476266Medicare PIN
KY00280047Medicare PIN
238204Medicare ID - Type Unspecified
FL378003100Medicaid
KY00151033Medicare PIN
KY00503009Medicare PIN