MEDICARE: MICHAEL JB GONZALEZ MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	MD11643	RI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	050513293	OTHER		UHP

General Provider Information

NPI Number	:	1265433908
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL JB GONZALEZ MD

Provider Business Mailing Address
First Line	:	10 DAVOL SQ
Second Line	:	SUITE 400
City	:	PROVIDENCE
State	:	RI
Zip	:	02903-4754
Country	:	US
Telephone Number	:	401-421-4000
Fax Number	:	401-272-1456

Provider Business Practice Location Address
First Line	:	360 KINGSTOWN RD
Second Line	:	SUITE 200
City	:	NARRAGANSETT
State	:	RI
Zip	:	02882-3239
Country	:	US
Telephone Number	:	401-783-6940
Fax Number	:	401-792-3676

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2005
Last Update Date	:	04/02/2024

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