Provider Demographics
NPI:1851606263
Name:PATRICK M. GONZALEZ, M.D., P.A.
Entity Type:Organization
Organization Name:PATRICK M. GONZALEZ, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNERR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:M
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:772-873-1005
Mailing Address - Street 1:1420 SW SAINT LUCIE WEST BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-1709
Mailing Address - Country:US
Mailing Address - Phone:772-873-1005
Mailing Address - Fax:772-873-9106
Practice Address - Street 1:1420 SW SAINT LUCIE WEST BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1709
Practice Address - Country:US
Practice Address - Phone:772-873-1005
Practice Address - Fax:772-873-9106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 67553208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377982300Medicaid
FLG16099Medicare UPIN
FL377982300Medicaid