Provider Demographics
NPI:1750398822
Name:GONZALES, ALEX L (MD)
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:L
Last Name:GONZALES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:4251 NW AMERICAN LN
Mailing Address - Street 2:STE 101
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-4881
Mailing Address - Country:US
Mailing Address - Phone:386-438-8541
Mailing Address - Fax:386-758-6046
Practice Address - Street 1:4251 NW AMERICAN LN
Practice Address - Street 2:STE 101
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-4881
Practice Address - Country:US
Practice Address - Phone:386-758-6143
Practice Address - Fax:386-758-6046
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2010-09-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME61910207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
15072OtherBCBS
FL266292200Medicaid
F30977Medicare UPIN
FL266292200Medicaid