Provider Demographics
NPI:1407077878
Name:GLENDA E GONZALEZ M.D. PA
Entity Type:Organization
Organization Name:GLENDA E GONZALEZ M.D. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:E
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-856-5633
Mailing Address - Street 1:1000 E OSCEOLA PKWY
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-1607
Mailing Address - Country:US
Mailing Address - Phone:407-847-7910
Mailing Address - Fax:407-932-2432
Practice Address - Street 1:1000 E OSCEOLA PKWY
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-1607
Practice Address - Country:US
Practice Address - Phone:407-847-7910
Practice Address - Fax:407-932-2432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0076730207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL267999000Medicaid
FLK5609Medicare PIN
FLG32727Medicare UPIN