Provider Demographics
NPI:1164138426
Name:GONZALEZ, OBDULIO
Entity Type:Individual
Prefix:
First Name:OBDULIO
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 1:4600 SW 160TH AVE APT 622
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-5770
Mailing Address - Country:US
Mailing Address - Phone:195-455-4872
Mailing Address - Fax:
Practice Address - Street 1:4649 PONCE DE LEON BLVD STE 404
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-2121
Practice Address - Country:US
Practice Address - Phone:786-536-9714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health