Provider Demographics
NPI:1356808497
Name:GONZALEZ, LISDAN SR
Entity type:Individual
Prefix:
First Name:LISDAN
Middle Name:
Last Name:GONZALEZ
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 NW 72ND AVE STE 3072
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3188
Mailing Address - Country:US
Mailing Address - Phone:305-396-3862
Mailing Address - Fax:305-396-8526
Practice Address - Street 1:777 NW 72ND AVE STE 3072
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-3188
Practice Address - Country:US
Practice Address - Phone:305-396-3862
Practice Address - Fax:305-396-8526
Is Sole Proprietor?:No
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC11651208100000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation