Healthcare Provider Details

I. General information

NPI: 1417080755
Provider Name (Legal Business Name): JORGE LUIS MONTANE-GONZALEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 05/20/2024
Certification Date: 05/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 E BLOOMINGDALE AVE STE 501
BRANDON FL
33511-8118
US

IV. Provider business mailing address

900 S PINE ISLAND RD STE 800
PLANTATION FL
33324-3923
US

V. Phone/Fax

Practice location:
  • Phone: 813-699-3995
  • Fax: 813-315-1625
Mailing address:
  • Phone: 813-699-3995
  • Fax: 813-315-1625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME52110
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: