MEDICARE: GUSTAVO GONZALEZ PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT16772	FL

General Provider Information

NPI Number	:	1205004009
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GUSTAVO GONZALEZ PT

Provider Business Mailing Address
First Line	:	14629 SW 104TH ST STE 148
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33186-2905
Country	:	US
Telephone Number	:	786-227-6843
Fax Number	:	786-227-6708

Provider Business Practice Location Address
First Line	:	14629 SW 104TH ST STE 148
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33186-2905
Country	:	US
Telephone Number	:	786-227-6843
Fax Number	:	786-227-6708

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2008
Last Update Date	:	12/31/2012

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