Provider Demographics
NPI:1912969395
Name:GONZALES, LEO T (M D)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:T
Last Name:GONZALES
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 95390
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70195-5390
Mailing Address - Country:US
Mailing Address - Phone:850-494-6560
Mailing Address - Fax:
Practice Address - Street 1:8383 N DAVIS HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-6039
Practice Address - Country:US
Practice Address - Phone:850-494-6560
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME74826207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL42802OtherBCBS PROVIDER NUMBER
FL42802Medicare ID - Type UnspecifiedMEDICARE NUMBER
FL42802OtherBCBS PROVIDER NUMBER