Provider Demographics
NPI:1639204019
Name:GONZALEZ, JUSTO (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTO
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JUSTO
Other - Middle Name:
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4420 S HOPKINS AVE
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-6690
Mailing Address - Country:US
Mailing Address - Phone:321-268-4693
Mailing Address - Fax:321-268-4696
Practice Address - Street 1:4420 S HOPKINS AVE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-6690
Practice Address - Country:US
Practice Address - Phone:321-268-4693
Practice Address - Fax:321-268-4696
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67177174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2716968-00Medicaid
FL2716968-00Medicaid
520717-K7029Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER