Healthcare Provider Details

I. General information

NPI: 1265433908
Provider Name (Legal Business Name): MICHAEL JB GONZALEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 04/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 KINGSTOWN RD SUITE 200
NARRAGANSETT RI
02882-3239
US

IV. Provider business mailing address

10 DAVOL SQ SUITE 400
PROVIDENCE RI
02903-4754
US

V. Phone/Fax

Practice location:
  • Phone: 401-783-6940
  • Fax: 401-792-3676
Mailing address:
  • Phone: 401-421-4000
  • Fax: 401-272-1456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD11643
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: