Provider Demographics
NPI:1073880290
Name:GONZALEZ, OSMAR
Entity Type:Individual
Prefix:
First Name:OSMAR
Middle Name:
Last Name:GONZALEZ
Suffix:
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 1:3900 NW 36TH STREET
Mailing Address - Street 2:SUITE 728
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166
Mailing Address - Country:US
Mailing Address - Phone:305-468-1714
Mailing Address - Fax:305-467-1757
Practice Address - Street 1:3900 NW 36TH STREET
Practice Address - Street 2:SUITE 728
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166
Practice Address - Country:US
Practice Address - Phone:305-468-1714
Practice Address - Fax:305-467-1757
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA62261225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist