Provider Demographics
NPI:1285641688
Name:GONZALEZ, DOMINIC (MD)
Entity Type:Individual
Prefix:
First Name:DOMINIC
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 1:38135 MARKET SQUARE
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542
Mailing Address - Country:US
Mailing Address - Phone:813-780-1255
Mailing Address - Fax:813-780-9773
Practice Address - Street 1:38135 MARKET SQUARE
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33542
Practice Address - Country:US
Practice Address - Phone:813-780-1255
Practice Address - Fax:813-780-9773
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME55279207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14581YMedicare PIN
C34161Medicare UPIN