Provider Demographics
NPI:1679527766
Name:GONZALEZ, BENJAMIN S (MD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:S
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 1:12200 TECH RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-1983
Mailing Address - Country:US
Mailing Address - Phone:301-622-2722
Mailing Address - Fax:
Practice Address - Street 1:12200 TECH RD
Practice Address - Street 2:SUITE 102
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904-1983
Practice Address - Country:US
Practice Address - Phone:301-622-2722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD068839L207P00000X
MDD-0065055207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018246820001Medicaid
PA44200Medicare ID - Type Unspecified
H06807Medicare UPIN