Healthcare Provider Details

I. General information

NPI: 1396585774
Provider Name (Legal Business Name): PROSPER MEDICAL OFFICE CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2024
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 NW 72ND AVE STE 377
MIAMI FL
33126-1920
US

IV. Provider business mailing address

1150 NW 72ND AVE STE 377
MIAMI FL
33126-1920
US

V. Phone/Fax

Practice location:
  • Phone: 305-457-0444
  • Fax:
Mailing address:
  • Phone: 305-457-0444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. RUBEN GONZALEZ
Title or Position: PRESIDENT
Credential: PTA
Phone: 305-457-0444