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General NPI Number Information
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NPI Number | 1629028865
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Entity Type | Organization
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Legal Business Name | ULTRA MEDICAL CENTER, CORP
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Dates
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Enumeration Date | 05/10/2006
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Last Update Date | 10/26/2009
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Provider Practice Location Address
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Address Line | 711 NW 23RD AVE SUITE 304
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City | MIAMI
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State | FL
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Zip | 33125-3298
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Country | US
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Telephone | 305-644-7407
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Fax | 305-644-7408
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Provider Business Mailing Address
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Address Line | 711 NW 23RD AVE SUITE 304
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City | MIAMI
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State | FL
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Zip | 33125-3298
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Country | US
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Telephone | 305-644-7407
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Fax | 305-644-7408
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Authorized Official
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Title or Position | OWNER
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Name | JOSE N GONZALEZ
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Credential | M.D
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Telephone | 305-644-7407
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 136410067
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License Number State | FL
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