MEDICARE: ALEX L GONZALES 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	207R00000X	Internal Medicine Physician	ME61910	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	15072	OTHER		BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750398822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEX L GONZALES MD

Provider Business Mailing Address
First Line	:	4251 NW AMERICAN LN
Second Line	:	STE 101
City	:	LAKE CITY
State	:	FL
Zip	:	32055-4881
Country	:	US
Telephone Number	:	386-438-8541
Fax Number	:	386-758-6046

Provider Business Practice Location Address
First Line	:	4251 NW AMERICAN LN
Second Line	:	STE 101
City	:	LAKE CITY
State	:	FL
Zip	:	32055-4881
Country	:	US
Telephone Number	:	386-758-6143
Fax Number	:	386-758-6046

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

Provider Enumeration Date	:	08/02/2006
Last Update Date	:	09/16/2010

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