Provider Demographics
NPI:1952414476
Name:GONZALEZ, MARIO SEGUNDO (MD FCAP FASCP)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:SEGUNDO
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MD FCAP FASCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 NASSAU ST
Mailing Address - Street 2:SUITE 216
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08542-4509
Mailing Address - Country:US
Mailing Address - Phone:609-924-3588
Mailing Address - Fax:609-924-3581
Practice Address - Street 1:111 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102
Practice Address - Country:US
Practice Address - Phone:973-877-5200
Practice Address - Fax:973-877-2468
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07983800207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIMG87904Medicaid
NJ095128Medicaid
NJ0081451Medicaid
NJ097096UPBMedicare ID - Type Unspecified
NJ095128Medicaid
F01856Medicare UPIN