Basic Information
| Provider Information | |||||||||
| NPI: | 1164637674 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | EDWARDO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GONZALEZ | ||||||||
| OtherFirstName: | JOSE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8600 NW 41ST ST | ||||||||
| Address2: | |||||||||
| City: | DORAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331666202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056425366 | ||||||||
| FaxNumber: | 3056446407 | ||||||||
| Practice Location | |||||||||
| Address1: | 12515 SW 88TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331861829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3056425366 | ||||||||
| FaxNumber: | 3056446407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2007 | ||||||||
| LastUpdateDate: | 01/15/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | 01063687A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
No ID Information.