1386746618 NPI number — DR. WIFREDO GONZALEZ MD

Table of content: DR. WIFREDO GONZALEZ MD (NPI 1386746618)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386746618 NPI number — DR. WIFREDO GONZALEZ MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALEZ
Provider First Name:
WIFREDO
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1386746618
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 3864
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30914-3864
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-737-4575
Provider Business Mailing Address Fax Number:
706-731-5289

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
288 S. RIDGECREST AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RUTHERFORDTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-286-5420
Provider Business Practice Location Address Fax Number:
706-731-5289
Provider Enumeration Date:
09/05/2006

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: 207L00000X , with the licence number:  00035342 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8936179 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1036209 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 36179 . This is a "BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5781203 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1194833855 . This is a "NPI - RUTHERFORD ANESTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 83095 . This is a "MEDCOST" identifier . This identifiers is of the category "OTHER".




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