Provider Demographics
NPI:1477621373
Name:GONZALEZ, GONZALO (MD)
Entity Type:Individual
Prefix:DR
First Name:GONZALO
Middle Name:
Last Name:GONZALEZ
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 1:2531 N DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33460-6250
Mailing Address - Country:US
Mailing Address - Phone:561-582-0330
Mailing Address - Fax:
Practice Address - Street 1:2531 N DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33460-6250
Practice Address - Country:US
Practice Address - Phone:561-582-0330
Practice Address - Fax:561-582-0339
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME99529208VP0014X, 207R00000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2803080100Medicaid
FL40681AMedicare UPIN
FLI08670Medicare UPIN