Provider Demographics
NPI:1790878148
Name:GONZALEZ, PETER G (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:G
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 1:2315 ROUTE 34
Mailing Address - Street 2:SUITE D
Mailing Address - City:MANASQUAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08736-1444
Mailing Address - Country:US
Mailing Address - Phone:732-974-0404
Mailing Address - Fax:732-974-2653
Practice Address - Street 1:2315 ROUTE 34
Practice Address - Street 2:SUITE D
Practice Address - City:MANASQUAN
Practice Address - State:NJ
Practice Address - Zip Code:08736-1444
Practice Address - Country:US
Practice Address - Phone:732-974-0404
Practice Address - Fax:732-974-2653
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101246363208100000X, 2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAPAROtherAETNA
VA-017OtherTRICARE/CHAMPUS
VAPAROtherCORVEL
VA1790878148OtherUNITED HEALTHCARE
VA1790878148OtherVIRGINIA PREMIER HEALTH PLAN
VA388453OtherANTHEM BC/BS
VAPAROtherUSA MANAGED CARE
VA10053837OtherOPTIMA HEALTH
VA1790878148Medicaid
NC5913812Medicaid
VAPAROtherCIGNA
VAPAROtherMULTIPLAN
VA1790878148OtherCOVENTRY HEALTH NETWORK
VAPAROtherVIRGINIA HEALTH NETWORK
NC5913812Medicaid
VA022026E30Medicare PIN
VAPAROtherCORVEL
VA1790878148OtherUNITED HEALTHCARE