Healthcare Provider Details

I. General information

NPI: 1164637674
Provider Name (Legal Business Name): DR. JOSE EDWARDO GONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JOSE GONZALEZ MD

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
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: 305-644-6407
Mailing address:
  • Phone: 305-642-5366
  • Fax: 305-644-6407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number01063687A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: