Healthcare Provider Details

I. General information

NPI: 1952307308
Provider Name (Legal Business Name): SERGIO G GONZALEZ MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 01/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 SOUTH 12TH AVENUE
LAUREL MS
39440-4322
US

IV. Provider business mailing address

119 SOUTH 12TH AVENUE
LAUREL MS
39440-4322
US

V. Phone/Fax

Practice location:
  • Phone: 601-425-9763
  • Fax: 601-428-5360
Mailing address:
  • Phone: 601-425-9763
  • Fax: 601-428-5360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number6914
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number06914
License Number StateMS

VIII. Authorized Official

Name: DR. SERGIO G GONZALEZ
Title or Position: DIRECTOR
Credential: MD
Phone: 601-649-5842