Provider Demographics
NPI:1942498985
Name:MARIO GONZALEZ, MD
Entity Type:Organization
Organization Name:MARIO GONZALEZ, MD
Other - Org Name:PRINCETON PATHOLOGY SERVICES PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-490-7206
Mailing Address - Street 1:PO BOX 144333
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-4333
Mailing Address - Country:US
Mailing Address - Phone:407-422-9831
Mailing Address - Fax:407-648-2065
Practice Address - Street 1:111 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-1909
Practice Address - Country:US
Practice Address - Phone:813-490-7206
Practice Address - Fax:813-886-6655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0083151Medicaid
NJ0083151Medicaid