Provider Demographics
NPI:1437442555
Name:GONZAGA GONZAGA, VICENTE MAURICIO (MD)
Entity Type:Individual
Prefix:
First Name:VICENTE
Middle Name:MAURICIO
Last Name:GONZAGA GONZAGA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11301 SE TEQUESTA TER
Mailing Address - Street 2:
Mailing Address - City:TEQUESTA
Mailing Address - State:FL
Mailing Address - Zip Code:33469-8146
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11301 SE TEQUESTA TER
Practice Address - Street 2:
Practice Address - City:TEQUESTA
Practice Address - State:FL
Practice Address - Zip Code:33469-8146
Practice Address - Country:US
Practice Address - Phone:561-744-0211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-23
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01072060A2084P0800X
CAC1641672084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201162750Medicaid