Provider Demographics
NPI:1174570154
Name:GONZALGO, MARK ANTHONY LOMIBAO (MD)
Entity type:Individual
Prefix:DR
First Name:MARK ANTHONY
Middle Name:LOMIBAO
Last Name:GONZALGO
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 1:1150 NW 14TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-2137
Mailing Address - Country:US
Mailing Address - Phone:305-243-4000
Mailing Address - Fax:305-243-6597
Practice Address - Street 1:1150 NW 14TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-2137
Practice Address - Country:US
Practice Address - Phone:305-243-4000
Practice Address - Fax:305-243-6597
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME116870208800000X, 208800000X
CAC53670208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD406479800Medicaid
MD406479800Medicaid
MDI24313Medicare UPIN