Provider Demographics
NPI:1164637674
Name:GONZALEZ, JOSE EDWARDO
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:EDWARDO
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JOSE
Other - Middle Name:
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:8600 NW 41ST ST
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6202
Mailing Address - Country:US
Mailing Address - Phone:305-642-5366
Mailing Address - Fax:305-644-6407
Practice Address - Street 1:12515 SW 88TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-1829
Practice Address - Country:US
Practice Address - Phone:305-642-5366
Practice Address - Fax:305-644-6407
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01063687A207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine