Healthcare Provider Details

I. General information

NPI: 1801193701
Provider Name (Legal Business Name): MANUEL OCTAVIO GONZALEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2011
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6050 W 20TH AVE FL 3
HIALEAH FL
33016-2605
US

IV. Provider business mailing address

6050 W 20TH AVE FL 3
HIALEAH FL
33016-2605
US

V. Phone/Fax

Practice location:
  • Phone: 786-584-5555
  • Fax: 786-584-5050
Mailing address:
  • Phone: 786-584-5555
  • Fax: 786-584-5050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number262848
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberME138174
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: