Healthcare Provider Details

I. General information

NPI: 1760648315
Provider Name (Legal Business Name): GONZALO N. GUTIERREZ BORGES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: GONZALO NICANOR GUTIERREZ BORGES MD

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 03/07/2023
Certification Date: 05/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 N JOHN YOUNG PKWY
KISSIMMEE FL
34741-4914
US

IV. Provider business mailing address

121 S ORANGE AVE STE 940
ORLANDO FL
32801-3234
US

V. Phone/Fax

Practice location:
  • Phone: 407-956-1920
  • Fax: 407-483-5844
Mailing address:
  • Phone: 407-658-9687
  • Fax: 407-286-4515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberSA00390
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberACN1033
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number19712
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: