MEDICARE: JOSE ANTONIO GONZALEZ

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	172A00000X	Driver	G524421600930	FL

General Provider Information

NPI Number	:	1205335734
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSE ANTONIO GONZALEZ

Provider Business Mailing Address
First Line	:	45 SOVEREIGN WAY
Second Line	:
City	:	HUTCHINSON ISLAND
State	:	FL
Zip	:	34949-8367
Country	:	US
Telephone Number	:	772-370-0101
Fax Number	:

Provider Business Practice Location Address
First Line	:	45 SOVEREIGN WAY
Second Line	:
City	:	HUTCHINSON ISLAND
State	:	FL
Zip	:	34949-8367
Country	:	US
Telephone Number	:	772-370-0101
Fax Number	:

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

Provider Enumeration Date	:	02/11/2018
Last Update Date	:	02/11/2018

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