=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750933321
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL ALEJANDRO GONZALEZ GOYRI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2019
-----------------------------------------------------
Last Update Date | 08/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 PALMETTO ST
-----------------------------------------------------
City | NEW SMYRNA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32168-7322
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-424-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 901 STERTHAUS DR
-----------------------------------------------------
City | ORMOND BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32174-5133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 164356
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------