Provider Demographics
NPI:1114070570
Name:GONZALEZ, JUAN JOSE (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:JOSE
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 OAKLEY SEAVER DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-1968
Mailing Address - Country:US
Mailing Address - Phone:321-235-0692
Mailing Address - Fax:321-235-0694
Practice Address - Street 1:1834 N ALAFAYA TRL
Practice Address - Street 2:SUITE A
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826-4743
Practice Address - Country:US
Practice Address - Phone:321-235-0692
Practice Address - Fax:321-235-0694
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR15837207RG0300X
FLME114422261QV0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVA
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRI-71448Medicare UPIN