Provider Demographics
NPI:1447364534
Name:GONZALEZ, PATRICK M (MD)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:M
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PATRICK
Other - Middle Name:M
Other - Last Name:GONZALEZ-RAMIL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1420 SW SAINT LUCIE WEST BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-1709
Mailing Address - Country:US
Mailing Address - Phone:772-873-1005
Mailing Address - Fax:772-873-9106
Practice Address - Street 1:1420 SW SAINT LUCIE WEST BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1709
Practice Address - Country:US
Practice Address - Phone:772-873-1005
Practice Address - Fax:772-873-9106
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 67553208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377982300Medicaid
FL59-3362726OtherEMPLOYER INDENTIF. NUMBER
FL27181Medicare ID - Type Unspecified
FL59-3362726OtherEMPLOYER INDENTIF. NUMBER