Healthcare Provider Details

I. General information

NPI: 1366443210
Provider Name (Legal Business Name): SERGIO G GONZALEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 S 12TH AVE
LAUREL MS
39440-4322
US

IV. Provider business mailing address

119 S 12TH AVE
LAUREL MS
39440-4322
US

V. Phone/Fax

Practice location:
  • Phone: 601-649-5842
  • Fax: 601-649-0726
Mailing address:
  • Phone: 601-649-5842
  • Fax: 601-649-0726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number06914
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number06914
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: