Provider Demographics
NPI:1508955964
Name:GONZALEZ, RODOLFO HECTOR (MD)
Entity Type:Individual
Prefix:DR
First Name:RODOLFO
Middle Name:HECTOR
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:RODOLFO
Other - Middle Name:HECTOR
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1860 TOWN CENTER DR
Mailing Address - Street 2:STE 350
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-5896
Mailing Address - Country:US
Mailing Address - Phone:703-435-8256
Mailing Address - Fax:703-435-3337
Practice Address - Street 1:1860 TOWN CENTER DR
Practice Address - Street 2:STE 350
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5896
Practice Address - Country:US
Practice Address - Phone:703-435-8256
Practice Address - Fax:703-435-3337
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101222040174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1003953928OtherNPI CORPORATION
VA1003953928OtherNPI CORPORATION
VA491547Medicare ID - Type UnspecifiedPROVIDER NUMBER