1790959963 NPI number — MR. CARLOS L GONZALEZ D.O.

Table of content: MR. CARLOS L GONZALEZ D.O. (NPI 1790959963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790959963 NPI number — MR. CARLOS L GONZALEZ D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALEZ
Provider First Name:
CARLOS
Provider Middle Name:
L
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790959963
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/17/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
418 MONACO DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUNTA GORDA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33950-7842
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-649-6112
Provider Business Mailing Address Fax Number:
305-649-1803

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1127 NW 22ND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33125-2738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-649-6112
Provider Business Practice Location Address Fax Number:
305-649-1803
Provider Enumeration Date:
04/17/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  DN13073 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100957200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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