Provider Demographics
NPI:1073119020
Name:GONZALEZ, DUSTIN (PT, DPT)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4671 NE 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33334-6032
Mailing Address - Country:US
Mailing Address - Phone:740-223-5052
Mailing Address - Fax:
Practice Address - Street 1:805 SE 3RD AVE STE 2
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-1193
Practice Address - Country:US
Practice Address - Phone:954-256-9052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT366642251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic