Provider Demographics
NPI:1265433908
Name:GONZALEZ, MICHAEL JB (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JB
Last Name:GONZALEZ
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Gender:M
Credentials:MD
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Mailing Address - Street 1:10 DAVOL SQ
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4754
Mailing Address - Country:US
Mailing Address - Phone:401-421-4000
Mailing Address - Fax:401-272-1456
Practice Address - Street 1:360 KINGSTOWN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:NARRAGANSETT
Practice Address - State:RI
Practice Address - Zip Code:02882-3239
Practice Address - Country:US
Practice Address - Phone:401-783-6940
Practice Address - Fax:401-792-3676
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2024-04-02
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Provider Licenses
StateLicense IDTaxonomies
RIMD11643207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
050513293OtherUHP
I25013Medicare UPIN