1073596813 NPI number — MANUEL F GONZALEZ M.D

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073596813 NPI number — MANUEL F GONZALEZ M.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALEZ
Provider First Name:
MANUEL
Provider Middle Name:
F
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D
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:
1073596813
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/27/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 N SUMTER ST
Provider Second Line Business Mailing Address:
SUITE 305
Provider Business Mailing Address City Name:
SUMTER
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29150-4972
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-934-8348
Provider Business Mailing Address Fax Number:
803-934-8349

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 N SUMTER ST
Provider Second Line Business Practice Location Address:
SUITE 305
Provider Business Practice Location Address City Name:
SUMTER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29150-4972
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-934-8348
Provider Business Practice Location Address Fax Number:
803-934-8349
Provider Enumeration Date:
11/25/2005

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: 174400000X , with the licence number:  9747 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RH0003X , with the licence number: 9747 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: GP4045 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: GP3381 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".