Healthcare Provider Details

I. General information

NPI: 1154346153
Provider Name (Legal Business Name): LEOPOLDO B GONZALEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 01/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 HEALTH PARK BLVD ANDERSON GIBBS BLDG., SUITE 221
ST AUGUSTINE FL
32086-5793
US

IV. Provider business mailing address

301 HEALTH PARK BLVD ANDERSON GIBBS BLDG., SUITE 221
ST AUGUSTINE FL
32086-5793
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-4277
  • Fax: 904-824-4490
Mailing address:
  • Phone: 904-824-4277
  • Fax: 904-824-4490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME0022097
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: