Provider Demographics
NPI:1295880565
Name:RICHARD D. GONZALES, M.D., P.C.
Entity type:Organization
Organization Name:RICHARD D. GONZALES, M.D., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-253-3366
Mailing Address - Street 1:735 MARTIN RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143-8411
Mailing Address - Country:US
Mailing Address - Phone:706-253-3366
Mailing Address - Fax:706-253-2243
Practice Address - Street 1:735 MARTIN RD
Practice Address - Street 2:SUITE A
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-8411
Practice Address - Country:US
Practice Address - Phone:706-253-3366
Practice Address - Fax:706-253-2243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044925207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00804251BMedicaid
GA08BDPCVMedicare ID - Type Unspecified
GA00804251BMedicaid