Provider Demographics
NPI:1336131671
Name:GONZALEZ, JESUS (MD)
Entity Type:Individual
Prefix:
First Name:JESUS
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 1:9980 CENTRAL PARK BLVD N STE 126
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428-1703
Mailing Address - Country:US
Mailing Address - Phone:561-375-2514
Mailing Address - Fax:
Practice Address - Street 1:9980 CENTRAL PARK BLVD N STE 126
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428-1703
Practice Address - Country:US
Practice Address - Phone:561-375-2514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME152847207R00000X
NC36188207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8936171Medicaid
F03246Medicare UPIN
NC8936171Medicaid