Provider Demographics
NPI:1598739609
Name:GONZALEZ, EVANGELIO (MD)
Entity Type:Individual
Prefix:DR
First Name:EVANGELIO
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 1:119 AMBULANCE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3857
Mailing Address - Country:US
Mailing Address - Phone:770-838-8710
Mailing Address - Fax:
Practice Address - Street 1:705 DALLAS HWY
Practice Address - Street 2:STE 101
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1247
Practice Address - Country:US
Practice Address - Phone:770-456-4411
Practice Address - Fax:770-812-3582
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016234207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00191496AMedicaid
AG6074570OtherDEA
AG6074570OtherDEA