Provider Demographics
NPI:1750333480
Name:GONZALEZ, MIGUEL E (MD)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:E
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 1:801 E DIXIE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-7601
Mailing Address - Country:US
Mailing Address - Phone:352-326-4031
Mailing Address - Fax:352-360-0257
Practice Address - Street 1:801 E DIXIE AVE STE 101
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-7601
Practice Address - Country:US
Practice Address - Phone:352-326-4031
Practice Address - Fax:352-360-0257
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME55600207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL10935300Medicaid
FL10935300Medicaid
FL09331UMedicare PIN
FL09331TMedicare PIN
FLE34042Medicare UPIN
FL09331ZMedicare PIN
FL09331SMedicare PIN
FL09331WMedicare PIN