MEDICARE: GONZALO A GONZALEZ MD PA

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	ME0062211	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	110215139	OTHER	FL	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	18166	OTHER	FL	BS FL
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1992931034
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GONZALO A GONZALEZ MD PA

Provider Business Mailing Address
First Line	:	PO BOX 2179
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33509-2179
Country	:	US
Telephone Number	:	813-633-6550
Fax Number	:	813-633-6551

Provider Business Practice Location Address
First Line	:	1653 SUN CITY CENTER PLZ
Second Line	:	SUITE 1002
City	:	SUN CITY CENTER
State	:	FL
Zip	:	33573-5394
Country	:	US
Telephone Number	:	813-633-6550
Fax Number	:	813-633-6551

Authorized Official
Title or Position	:	BILLING/CONTRACTING
Name	:	MRS. ELENA BOUSQUET GALBIS
Credential	:
Telephone Number	:	863-686-0989

Provider Enumeration Date	:	06/03/2009
Last Update Date	:	06/03/2009

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