Provider Demographics
NPI:1700633997
Name:GONZALEZ, JORGE ANGEL (PMD)
Entity type:Individual
Prefix:MR
First Name:JORGE
Middle Name:ANGEL
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:PMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15476 NW 77TH CT STE 447
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-5823
Mailing Address - Country:US
Mailing Address - Phone:786-200-9189
Mailing Address - Fax:
Practice Address - Street 1:15476 NW 77TH CT STE 447
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33016-5823
Practice Address - Country:US
Practice Address - Phone:786-200-9189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-04
Last Update Date:2024-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL522048146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL522048OtherPMD