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General NPI Number Information
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NPI Number | 1336337690
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Entity Type | Organization
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Legal Business Name | SPACE COAST UROLOGY, LLC
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Dates
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Enumeration Date | 10/11/2007
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Last Update Date | 03/13/2009
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Provider Practice Location Address
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Address Line | 2203 GARDEN ST
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City | TITUSVILLE
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State | FL
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Zip | 32796-2577
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Country | US
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Telephone | 321-268-4693
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Fax | 321-268-4696
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Provider Business Mailing Address
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Address Line | 2203 GARDEN ST
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City | TITUSVILLE
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State | FL
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Zip | 32796-2577
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Country | US
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Telephone | 321-268-4693
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Fax | 321-268-4696
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Authorized Official
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Title or Position | UROLOGIST
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Name | DR. JUSTO GONZALEZ
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Credential | M.D.
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Telephone | 321-268-4693
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | ME67177
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License Number State | FL
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