=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417103045
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEOPOLDO B GONZALEZ MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2008
-----------------------------------------------------
Last Update Date | 02/18/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 HEALTH PARK BLVD SUITE 323
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32086-5793
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-824-4277
-----------------------------------------------------
Fax | 904-824-4490
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 HEALTH PARK BLVD SUITE 323
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32086-5793
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-824-4277
-----------------------------------------------------
Fax | 904-824-4490
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. LEOPOLDO B GONZALEZ
-----------------------------------------------------
Credential | MDPA
-----------------------------------------------------
Telephone | 904-824-4277
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | ME0022097
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------