Basic Information
Provider Information | |||||||||
NPI: | 1740226190 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GONZALEZ | ||||||||
FirstName: | MANUEL | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 266211 | ||||||||
Address2: |   | ||||||||
City: | WESTON | ||||||||
State: | FL | ||||||||
PostalCode: | 333266211 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5619674118 | ||||||||
FaxNumber: | 5619673463 | ||||||||
Practice Location | |||||||||
Address1: | 747 PONCE DE LEON BLVD | ||||||||
Address2: | SUITE 605 | ||||||||
City: | CORAL GABLES | ||||||||
State: | FL | ||||||||
PostalCode: | 331342049 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3056654614 | ||||||||
FaxNumber: | 3056670239 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/22/2006 | ||||||||
LastUpdateDate: | 05/14/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME83670 | FL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RC0200X | ME83670 | FL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | ME83670 | FL | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | 264849100 | 01 | FL | PSN | OTHER | N210329 | 01 | FL | WELLCARE | OTHER | 264849100 | 05 | FL |   | MEDICAID | 51993 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER |