=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932405230
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIGUEL E GONZALEZ MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2011
-----------------------------------------------------
Last Update Date | 12/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6720 TAFT ST
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33024-3903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-964-0070
-----------------------------------------------------
Fax | 954-964-4289
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6720 TAFT ST
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33024-3903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-964-0070
-----------------------------------------------------
Fax | 954-964-4289
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MIGUEL E GONZALEZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 954-964-0070
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | ME 55600
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------