Provider Demographics
NPI:1912223025
Name:GONZALEZ, FERNANDO (MD)
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:
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 1:111 MALTESE DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940-2115
Mailing Address - Country:US
Mailing Address - Phone:845-342-4774
Mailing Address - Fax:845-343-8741
Practice Address - Street 1:111 MALTESE DR
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-2115
Practice Address - Country:US
Practice Address - Phone:845-342-4774
Practice Address - Fax:845-343-8741
Is Sole Proprietor?:No
Enumeration Date:2010-04-14
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY263083208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400057668OtherMEDICARE