=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164637674
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. JOSE EDWARDO GONZALEZ
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2007
-----------------------------------------------------
Last Update Date | 01/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12515 SW 88TH ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33186-1829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-642-5366
-----------------------------------------------------
Fax | 305-644-6407
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8600 NW 41ST ST
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33166-6202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-642-5366
-----------------------------------------------------
Fax | 305-644-6407
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 01063687A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------