Provider Demographics
NPI:1962792580
Name:GONZALEZ HERNANDEZ, JESSICA (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:GONZALEZ HERNANDEZ
Suffix:
Gender:F
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:PO BOX 743294
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3294
Mailing Address - Country:US
Mailing Address - Phone:787-349-0120
Mailing Address - Fax:
Practice Address - Street 1:CAROLINA SURGICAL ASSOCIATES EASTSIDE
Practice Address - Street 2:135 COMMONWEALTH DRIVE STE 210
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4850
Practice Address - Country:US
Practice Address - Phone:864-675-4815
Practice Address - Fax:877-893-3779
Is Sole Proprietor?:No
Enumeration Date:2011-04-15
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC61156208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC611564Medicaid