Healthcare Provider Details

I. General information

NPI: 1730519836
Provider Name (Legal Business Name): JORGE GAMONEDA SA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2013
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3661 S MIAMI AVE SUITE 708
MIAMI FL
33133
US

IV. Provider business mailing address

9804 SW 40TH ST STE 708
MIAMI FL
33165-3912
US

V. Phone/Fax

Practice location:
  • Phone: 305-858-9879
  • Fax:
Mailing address:
  • Phone: 305-222-9154
  • Fax: 305-222-9155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number04-178
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: