Healthcare Provider Details

I. General information

NPI: 1790996908
Provider Name (Legal Business Name): TONY MELVILLE GONSALVES D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2007
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14349 GIDEON DR FL 2
WOODBRIDGE VA
22192-4641
US

IV. Provider business mailing address

14349 GIDEON DR FL 2
WOODBRIDGE VA
22192-4641
US

V. Phone/Fax

Practice location:
  • Phone: 571-472-8762
  • Fax: 571-447-2672
Mailing address:
  • Phone: 571-472-8762
  • Fax: 571-472-8762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102202522
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: