=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679089890
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEXANDER MICHAEL GONZALEZ
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/26/2017
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15600 NW 67TH AVE
-----------------------------------------------------
City | MIAMI LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33014-2174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-828-8260
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4081 W 6TH CT
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33012-3818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OTT18884
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------