Healthcare Provider Details

I. General information

NPI: 1528281409
Provider Name (Legal Business Name): IVAN ALBERTO GONZALEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 08/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1580 N.W. 10TH AVENUE, LOCATOR CODE D4-4
MIAMI FL
33136
US

IV. Provider business mailing address

1580 N.W. 10TH AVENUE, LOCATOR CODE D4-4
MIAMI FL
33136
US

V. Phone/Fax

Practice location:
  • Phone: 305-243-6522
  • Fax: 305-243-5562
Mailing address:
  • Phone: 305-243-6522
  • Fax: 305-243-5562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License NumberME 102105
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: