Basic Information
| Provider Information | |||||||||
| NPI: | 1639116593 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JUNCO | ||||||||
| FirstName: | AIDA | ||||||||
| MiddleName: | GONZALEZ | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12300 SW 2 ST | ||||||||
| Address2: | |||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9546101720 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12300 SW 2 ST | ||||||||
| Address2: | |||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544728587 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 12/19/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME 42310 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | ME42310 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 266141100 | 05 | FL | MEDICAID |