Provider Demographics
NPI:1376077099
Name:GONZALEZ, MARIO A
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:A
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5566 26TH AVE SW
Mailing Address - Street 2:APT B
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34116-7553
Mailing Address - Country:US
Mailing Address - Phone:239-300-5076
Mailing Address - Fax:
Practice Address - Street 1:5566 26TH AVE SW
Practice Address - Street 2:APT B
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34116-7553
Practice Address - Country:US
Practice Address - Phone:239-300-5076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL17000000604347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle