Provider Demographics
NPI:1881673796
Name:VILLALOBOS, GONZALO (MD)
Entity Type:Individual
Prefix:DR
First Name:GONZALO
Middle Name:
Last Name:VILLALOBOS
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 1:200 CORPORATE BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:743 SPRING ST NE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3715
Practice Address - Country:US
Practice Address - Phone:770-536-2146
Practice Address - Fax:770-536-7895
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043143207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000742563JMedicaid
GA000742563NOtherMEDICAID URGENT CARE FRIENDSHIP
GA93BFDXROtherMEDICARE PIN URGENT CARE FRIENDSHIP
GA000742563KMedicaid
GA000742563MMedicaid
GA000742563JMedicaid
GA000742563NOtherMEDICAID URGENT CARE FRIENDSHIP
GA93BBGNDMedicare ID - Type Unspecified