Basic Information
| Provider Information | |||||||||
| NPI: | 1720187610 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ-GOMEZ | ||||||||
| FirstName: | IGNACIO | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 6TH AVE S | ||||||||
| Address2: | BOX 6941 | ||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337014634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277674429 | ||||||||
| FaxNumber: | 7277674970 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 6TH AVE S | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337014634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277674341 | ||||||||
| FaxNumber: | 7277678516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 03/03/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0213X | ME104028 | FL | Y | Allopathic & Osteopathic Physicians | Pathology | Pediatric Pathology |
ID Information
| ID | Type | State | Issuer | Description | 1981246 | 01 | FL | CIGNA | OTHER | 1454H | 01 | FL | BLUE CROSS/BLUE SHIELD | OTHER | 294635 | 01 | FL | STAYWELL/HEALTHEASE | OTHER | 00A670490 | 05 | CA | MEDICAID | 331553 | 01 | FL | AVMED | OTHER | 000782800 | 05 | FL | MEDICAID | 7913502 | 01 | FL | AETNA | OTHER |