Healthcare Provider Details

I. General information

NPI: 1053487603
Provider Name (Legal Business Name): ALFREDO V GONZALES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701S.E. HILLMOOR DR. SUITE #4
PORT ST. LUCIE FL
34952
US

IV. Provider business mailing address

1701 SE HILLMOOR DR SUITE #4
PORT ST LUCIE FL
34952-7552
US

V. Phone/Fax

Practice location:
  • Phone: 772-335-5656
  • Fax:
Mailing address:
  • Phone: 772-335-5656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME30145
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: