Provider Demographics
NPI:1750354361
Name:GONZALEZ, JOSE L
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:L
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JOSE
Other - Middle Name:L
Other - Last Name:GONZALEZ, GONZALEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 95004
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33804-5004
Mailing Address - Country:US
Mailing Address - Phone:863-680-7206
Mailing Address - Fax:863-680-7420
Practice Address - Street 1:1600 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805
Practice Address - Country:US
Practice Address - Phone:863-680-7000
Practice Address - Fax:866-264-8519
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9202589367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL306224400Medicaid
Q18465Medicare UPIN
FLG3482ZMedicare PIN