Basic Information
| Provider Information | |||||||||
| NPI: | 1669446480 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VALDIVIA | ||||||||
| FirstName: | GONZALO | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 650 S COURTENAY PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MERRITT ISLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329524977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213942660 | ||||||||
| FaxNumber: | 3213942669 | ||||||||
| Practice Location | |||||||||
| Address1: | 1421 MALABAR RD NE | ||||||||
| Address2: | STE 200 | ||||||||
| City: | PALM BAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329072576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3213082660 | ||||||||
| FaxNumber: | 3219849303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2006 | ||||||||
| LastUpdateDate: | 08/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | ME81813 | FL | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | P00037101 | 01 | FL | MEDICARE RAILROAD | OTHER | 114495500 | 05 | FL | MEDICAID |