Healthcare Provider Details

I. General information

NPI: 1114070570
Provider Name (Legal Business Name): JUAN JOSE GONZALEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 01/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1834 N ALAFAYA TRL SUITE A
ORLANDO FL
32826-4743
US

IV. Provider business mailing address

805 OAKLEY SEAVER DR SUITE A
CLERMONT FL
34711-1968
US

V. Phone/Fax

Practice location:
  • Phone: 321-235-0692
  • Fax: 321-235-0694
Mailing address:
  • Phone: 321-235-0692
  • Fax: 321-235-0694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number15837
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License NumberME114422
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: