MEDICARE: KETTY 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	247200000X	Other Technician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1497103113
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KETTY GONZALEZ

Provider Business Mailing Address
First Line	:	771 SE 2ND PL
Second Line	:
City	:	HIALEAH
State	:	FL
Zip	:	33010-5405
Country	:	US
Telephone Number	:	305-801-5996
Fax Number	:

Provider Business Practice Location Address
First Line	:	12855 SW 132ND ST
Second Line	:	SUITE 207
City	:	MIAMI
State	:	FL
Zip	:	33186-7207
Country	:	US
Telephone Number	:	786-587-0424
Fax Number	:	786-250-5094

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

Provider Enumeration Date	:	06/03/2016
Last Update Date	:	06/03/2016

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Directions to “ KETTY GONZALEZ ” Practice Location

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