Provider Demographics
NPI:1881199560
Name:GONZALEZ, SAM C (MD)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:C
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MD
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Other - Last Name:
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Mailing Address - Street 1:960 MASSACHUSETTS AVE
Mailing Address - Street 2:FL 2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:637 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124-3510
Practice Address - Country:US
Practice Address - Phone:617-825-9660
Practice Address - Fax:617-288-7898
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA2866212083P0500X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine