Provider Demographics
NPI:1194021436
Name:GONZALEZ, RAUL ALBERTO
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:ALBERTO
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 1:14600 SW 87TH CT
Mailing Address - Street 2:
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33176-8018
Mailing Address - Country:US
Mailing Address - Phone:786-975-4498
Mailing Address - Fax:305-400-8793
Practice Address - Street 1:14600 SW 87TH CT
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33176-8018
Practice Address - Country:US
Practice Address - Phone:786-975-4498
Practice Address - Fax:305-400-8793
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-03
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME58558225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist