Provider Demographics
NPI:1447286257
Name:GONZALEZ, GUSTAVO A JR (MD)
Entity type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:A
Last Name:GONZALEZ
Suffix:JR
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 1:14050 NW 14TH ST
Mailing Address - Street 2:SUITE 190
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2865
Mailing Address - Country:US
Mailing Address - Phone:800-424-3672
Mailing Address - Fax:954-377-3042
Practice Address - Street 1:801 S DOUGLAS RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33025-1355
Practice Address - Country:US
Practice Address - Phone:954-985-1470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2021-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67840207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL27762OtherBLUE SHIELD
FL379098300Medicaid
FL27762UMedicare ID - Type Unspecified