Provider Demographics
NPI:1679723902
Name:GONZALEZ, VICTORIA BEATRIZ (AUD)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:BEATRIZ
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-4775
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:DEPARTMENT OF OTOLARYNGOLOGY
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-815-4775
Practice Address - Fax:601-984-6451
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY1572231H00000X, 237600000X
MSA3705231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002917500Medicaid
FL002917501Medicaid
MS00336063Medicaid
EI480ZMedicare PIN
FL002917501Medicaid