Healthcare Provider Details

I. General information

NPI: 1477541720
Provider Name (Legal Business Name): GONZALO HUAMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 02/08/2018
Certification Date:
Deactivation Date: 01/11/2018
Reactivation Date: 02/08/2018

III. Provider practice location address

1403 MEDICAL PLAZA DR SUITE 101
SANFORD FL
32771-1000
US

IV. Provider business mailing address

1403 MEDICAL PLAZA DR SUITE 101
SANFORD FL
32771-1000
US

V. Phone/Fax

Practice location:
  • Phone: 407-322-0090
  • Fax: 407-321-3783
Mailing address:
  • Phone: 407-322-0090
  • Fax: 407-321-3783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME11457
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: