Provider Demographics
NPI:1700111614
Name:GONZALEZ SAMOT, GLORIMAR (MD)
Entity Type:Individual
Prefix:
First Name:GLORIMAR
Middle Name:
Last Name:GONZALEZ SAMOT
Suffix:
Gender:F
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:PO BOX 5618
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33807-5618
Mailing Address - Country:US
Mailing Address - Phone:813-588-5123
Mailing Address - Fax:
Practice Address - Street 1:675 S KINGS AVE STE 101
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6048
Practice Address - Country:US
Practice Address - Phone:813-588-5123
Practice Address - Fax:863-646-9664
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-09
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17491208D00000X
FLACN784208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLACN784OtherMEDICAL LICENSE NUMBER