Provider Demographics
NPI:1407494909
Name:GONZALEZ LAVANDEROS, JOSE JORGE
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:JORGE
Last Name:GONZALEZ LAVANDEROS
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 1:6800 SW 18TH CT
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33068-4326
Mailing Address - Country:US
Mailing Address - Phone:954-422-6500
Mailing Address - Fax:
Practice Address - Street 1:6800 SW 18TH CT
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33068-4326
Practice Address - Country:US
Practice Address - Phone:954-422-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-16
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17-302246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant