Healthcare Provider Details

I. General information

NPI: 1134083397
Provider Name (Legal Business Name): THEODORE RAFAEL GONZALEZ APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11541 SW 98TH CT
MIAMI FL
33176-4107
US

IV. Provider business mailing address

PO BOX 562583
MIAMI FL
33256-2583
US

V. Phone/Fax

Practice location:
  • Phone: 786-471-4271
  • Fax: 888-637-3889
Mailing address:
  • Phone: 786-471-4271
  • Fax: 888-637-3889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberAPRN11044009
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: