Provider Demographics
NPI:1952307308
Name:SERGIO G GONZALEZ MD PA
Entity Type:Organization
Organization Name:SERGIO G GONZALEZ MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:G
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-649-5842
Mailing Address - Street 1:119 SOUTH 12TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39440-4322
Mailing Address - Country:US
Mailing Address - Phone:601-425-9763
Mailing Address - Fax:601-428-5360
Practice Address - Street 1:119 SOUTH 12TH AVENUE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4322
Practice Address - Country:US
Practice Address - Phone:601-425-9763
Practice Address - Fax:601-428-5360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS6914207ZD0900X
MS06914208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS512G70024OtherMEDICARE GROUP
MS00013124Medicaid
MS00013124Medicaid