Provider Demographics
NPI:1417103045
Name:LEOPOLDO B GONZALEZ MD PA
Entity Type:Organization
Organization Name:LEOPOLDO B GONZALEZ MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEOPOLDO
Authorized Official - Middle Name:B
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MDPA
Authorized Official - Phone:904-824-4277
Mailing Address - Street 1:301 HEALTH PARK BLVD
Mailing Address - Street 2:SUITE 323
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5793
Mailing Address - Country:US
Mailing Address - Phone:904-824-4277
Mailing Address - Fax:904-824-4490
Practice Address - Street 1:301 HEALTH PARK BLVD
Practice Address - Street 2:SUITE 323
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5793
Practice Address - Country:US
Practice Address - Phone:904-824-4277
Practice Address - Fax:904-824-4490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-14
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0022097208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL054187700Medicaid
FL18014Medicare PIN