Basic Information
| Provider Information | |||||||||
| NPI: | 1649211293 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GONZALEZ | ||||||||
| FirstName: | JORGE | ||||||||
| MiddleName: | FEDERICO | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1845 N HIGHWAY A1A | ||||||||
| Address2: | |||||||||
| City: | INDIALANTIC | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329032651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217790804 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2900 VETERANS WAY | ||||||||
| Address2: | |||||||||
| City: | VIERA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329408007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216373788 | ||||||||
| FaxNumber: | 3216373548 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | ME 61754 | FL | X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0600X | ME 61754 | FL | X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology |
No ID Information.