Provider Demographics
NPI:1780293068
Name:GONZALEZ, GUILLERMO I (CORP)
Entity type:Individual
Prefix:MR
First Name:GUILLERMO
Middle Name:
Last Name:GONZALEZ
Suffix:I
Gender:M
Credentials:CORP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1037 NE PINE ISLAND LN
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33909-2176
Mailing Address - Country:US
Mailing Address - Phone:305-680-6865
Mailing Address - Fax:
Practice Address - Street 1:1037 NE PINE ISLAND LN
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-2176
Practice Address - Country:US
Practice Address - Phone:305-680-6865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17-085-4043172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO17-085-4043Medicaid