Healthcare Provider Details

I. General information

NPI: 1386746618
Provider Name (Legal Business Name): WIFREDO GONZALEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 06/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

288 S. RIDGECREST AVENUE
RUTHERFORDTON NC
28139
US

IV. Provider business mailing address

P.O. BOX 3864
AUGUSTA GA
30914-3864
US

V. Phone/Fax

Practice location:
  • Phone: 828-286-5420
  • Fax: 706-731-5289
Mailing address:
  • Phone: 706-737-4575
  • Fax: 706-731-5289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number00035342
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: