Provider Demographics
NPI:1366617987
Name:GONZALEZ, LEONCIO G (MD)
Entity type:Individual
Prefix:
First Name:LEONCIO
Middle Name:G
Last Name:GONZALEZ
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 1:91 PLEASANT HILL RD
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869
Mailing Address - Country:US
Mailing Address - Phone:973-927-6519
Mailing Address - Fax:
Practice Address - Street 1:400 W BLACKWELL ST
Practice Address - Street 2:ST CLARES HOSPITAL
Practice Address - City:DOVER
Practice Address - State:NJ
Practice Address - Zip Code:07801
Practice Address - Country:US
Practice Address - Phone:973-927-6519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04600100208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice