Provider Demographics
NPI:1376881680
Name:GONZALEZ, MIRIAM C
Entity Type:Individual
Prefix:DR
First Name:MIRIAM
Middle Name:C
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2990 FIVE FORKS TRICKUM RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-5872
Mailing Address - Country:US
Mailing Address - Phone:770-978-6475
Mailing Address - Fax:
Practice Address - Street 1:2990 FIVE FORKS TRICKUM RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-5872
Practice Address - Country:US
Practice Address - Phone:770-978-6475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-21
Last Update Date:2022-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH015699183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1376881680Medicaid