Healthcare Provider Details

I. General information

NPI: 1073997102
Provider Name (Legal Business Name): KATIUSKA GONZALEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2015
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12515 SW 88TH ST
MIAMI FL
33186-1829
US

IV. Provider business mailing address

8600 NW 41ST ST
DORAL FL
33166-6202
US

V. Phone/Fax

Practice location:
  • Phone: 305-642-5366
  • Fax:
Mailing address:
  • Phone: 305-642-5366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31591
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME130178
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: