Healthcare Provider Details

I. General information

NPI: 1295726933
Provider Name (Legal Business Name): PAUL W. GONTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 05/03/2022
Certification Date: 05/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 SUNSET LAKE BLVD SUITE 101
VENICE FL
34292-7554
US

IV. Provider business mailing address

PO BOX 102222 ATTN: CREDENTIAL DEPARTMENT
ATLANTA GA
30368-2222
US

V. Phone/Fax

Practice location:
  • Phone: 941-408-0500
  • Fax: 941-496-8558
Mailing address:
  • Phone: 239-274-8200
  • Fax: 239-278-3350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License NumberME85932
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberME85932
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: