Provider Demographics
NPI:1801933171
Name:CARRIZO, GONZALO JAVIER (MD)
Entity type:Individual
Prefix:
First Name:GONZALO
Middle Name:JAVIER
Last Name:CARRIZO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2380 HARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5024
Mailing Address - Country:US
Mailing Address - Phone:941-260-0325
Mailing Address - Fax:941-766-0423
Practice Address - Street 1:2380 HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5024
Practice Address - Country:US
Practice Address - Phone:941-260-0325
Practice Address - Fax:941-766-0423
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.131527208G00000X
COTL-1905390200000X
FLME103088208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000612700Medicaid
FLP00717548OtherRR MEDICARE
FLBS476ZMedicare PIN