Provider Demographics
NPI:1679791701
Name:ERNEST GONZALEZ
Entity Type:Organization
Organization Name:ERNEST GONZALEZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-328-9484
Mailing Address - Street 1:800 ZEAGLER DR
Mailing Address - Street 2:SUITE600
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-3867
Mailing Address - Country:US
Mailing Address - Phone:386-328-9484
Mailing Address - Fax:386-328-6569
Practice Address - Street 1:800 ZEAGLER DR
Practice Address - Street 2:SUITE600
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-3867
Practice Address - Country:US
Practice Address - Phone:386-328-9484
Practice Address - Fax:386-328-6569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0038861208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL373443900Medicaid
FL373443900Medicaid