Provider Demographics
NPI:1730380916
Name:GONZAGA, MARIA VIRGINIA (MD)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:VIRGINIA
Last Name:GONZAGA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 10TH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-3600
Mailing Address - Country:US
Mailing Address - Phone:706-341-3311
Mailing Address - Fax:706-341-3096
Practice Address - Street 1:1900 10TH AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-3600
Practice Address - Country:US
Practice Address - Phone:706-341-3311
Practice Address - Fax:706-341-3096
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2016-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA70627207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I164305OtherMEDICARE PTAN
GA202I164305OtherMEDICARE PTAN