Provider Demographics
NPI:1043482813
Name:GONZALES, POTENCIANO D (MD)
Entity type:Individual
Prefix:
First Name:POTENCIANO
Middle Name:D
Last Name:GONZALES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 SPRING VISTA DR STE 101
Mailing Address - Street 2:
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-1812
Mailing Address - Country:US
Mailing Address - Phone:386-668-8559
Mailing Address - Fax:386-668-8560
Practice Address - Street 1:62 SPRING VISTA DR STE 100
Practice Address - Street 2:
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-1812
Practice Address - Country:US
Practice Address - Phone:386-668-8559
Practice Address - Fax:386-668-8560
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-01
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME70587207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251651900Medicaid
FL32857AMedicare PIN
FL080183159Medicare PIN