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General NPI Number Information
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NPI Number | 1043541162
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Entity Type | Organization
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Legal Business Name | POTENCIANO GONZALES MD PA
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Dates
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Enumeration Date | 01/29/2010
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Last Update Date | 09/30/2010
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Provider Practice Location Address
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Address Line | 62 SPRING VISTA DR STE 100
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City | DEBARY
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State | FL
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Zip | 32713-1812
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Country | US
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Telephone | 386-668-8559
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Fax |
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Provider Business Mailing Address
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Address Line | 62 SPRING VISTA DR STE 101
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City | DEBARY
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State | FL
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Zip | 32713-1812
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Country | US
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Telephone | 386-668-8559
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. POTENCIANO DIVINO GONZALES JR.
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Credential | MD
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Telephone | 386-668-8559
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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