Provider Demographics
NPI:1902163801
Name:MIGUEL A GONZALEZ M.D. P.A
Entity Type:Organization
Organization Name:MIGUEL A GONZALEZ M.D. P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:ANGEL
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-523-8108
Mailing Address - Street 1:401 SE 16TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-2529
Mailing Address - Country:US
Mailing Address - Phone:954-523-8108
Mailing Address - Fax:954-525-9828
Practice Address - Street 1:401 SE 16TH ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2529
Practice Address - Country:US
Practice Address - Phone:954-523-8108
Practice Address - Fax:954-525-9828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL24288261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL035917300Medicaid
FL035917300Medicaid
FL71948Medicare PIN