Provider Demographics
NPI:1336246073
Name:POTENCIANO D GONZALES MD
Entity Type:Organization
Organization Name:POTENCIANO D GONZALES MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:POTENCIANO
Authorized Official - Middle Name:D
Authorized Official - Last Name:GONZALES
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:386-668-8559
Mailing Address - Street 1:317 HAZELTINE DR
Mailing Address - Street 2:
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-4561
Mailing Address - Country:US
Mailing Address - Phone:386-668-8559
Mailing Address - Fax:386-668-8560
Practice Address - Street 1:70 FOX RIDGE CT
Practice Address - Street 2:SUITE B
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-2752
Practice Address - Country:US
Practice Address - Phone:386-668-8559
Practice Address - Fax:386-668-8560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-17
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL32857AMedicare UPIN