Healthcare Provider Details

I. General information

NPI: 1144547399
Provider Name (Legal Business Name): FANNY GONZALEZ, M.D. P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2010
Last Update Date: 05/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 SW 3RD AVE UNIT CU1
MIAMI FL
33129-2056
US

IV. Provider business mailing address

PO BOX 144653
CORAL GABLES FL
33114-4653
US

V. Phone/Fax

Practice location:
  • Phone: 305-856-7005
  • Fax: 305-856-7533
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License NumberME106001
License Number StateFL

VIII. Authorized Official

Name: DR. FANNY GONZALEZ
Title or Position: OWNER
Credential: M.D.
Phone: 305-856-7005