Healthcare Provider Details

I. General information

NPI: 1407409386
Provider Name (Legal Business Name): ALEXIS ROBERTO GONZALEZ VALLES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2019
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1931 S NARCOOSSEE RD
SAINT CLOUD FL
34771-7211
US

IV. Provider business mailing address

425 W COLONIAL DR STE 303
ORLANDO FL
32804-6863
US

V. Phone/Fax

Practice location:
  • Phone: 407-986-9642
  • Fax: 407-593-6102
Mailing address:
  • Phone: 321-332-6947
  • Fax: 407-286-4515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberACN1234
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number21503
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN1234
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: