Provider Demographics
NPI:1306864913
Name:GONZALEZ, E (MD PA)
Entity Type:Individual
Prefix:DR
First Name:E
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4755 SUMMERLIN RD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-1073
Mailing Address - Country:US
Mailing Address - Phone:239-275-5339
Mailing Address - Fax:239-275-5592
Practice Address - Street 1:4755 SUMMERLIN RD
Practice Address - Street 2:SUITE 8
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-1073
Practice Address - Country:US
Practice Address - Phone:239-275-5339
Practice Address - Fax:239-275-5592
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME25089207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL036797400Medicaid
FLD86283Medicare UPIN
FL78390AMedicare ID - Type Unspecified