Provider Demographics
NPI:1558467191
Name:GONZALEZ, LAURA KIMBERLEY (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:KIMBERLEY
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4802 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-2916
Mailing Address - Country:US
Mailing Address - Phone:718-283-7885
Mailing Address - Fax:718-635-7228
Practice Address - Street 1:4802 10TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2916
Practice Address - Country:US
Practice Address - Phone:718-283-7885
Practice Address - Fax:718-635-7228
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008009076207PE0004X
NY264679207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO152360014Medicare PIN
MOP00663595Medicare PIN