Healthcare Provider Details

I. General information

NPI: 1336766302
Provider Name (Legal Business Name): JOSE EMANUEL MELENDEZ GONZALEZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2020
Last Update Date: 03/19/2023
Certification Date: 03/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11750 SW 40TH ST
MIAMI FL
33175-3530
US

IV. Provider business mailing address

URB MEDINA CALLE 5 CASA D-40
ISABELA PR
00662-3833
US

V. Phone/Fax

Practice location:
  • Phone: 305-223-3000
  • Fax:
Mailing address:
  • Phone: 787-454-9128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number15456-I
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: