Healthcare Provider Details

I. General information

NPI: 1417103045
Provider Name (Legal Business Name): LEOPOLDO B GONZALEZ MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2008
Last Update Date: 02/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 HEALTH PARK BLVD SUITE 323
ST AUGUSTINE FL
32086-5793
US

IV. Provider business mailing address

301 HEALTH PARK BLVD SUITE 323
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 Code208600000X
TaxonomySurgery Physician
License NumberME0022097
License Number StateFL

VIII. Authorized Official

Name: DR. LEOPOLDO B GONZALEZ
Title or Position: OWNER
Credential: MDPA
Phone: 904-824-4277