Provider Demographics
NPI:1477541720
Name:HUAMAN, GONZALO (MD)
Entity Type:Individual
Prefix:DR
First Name:GONZALO
Middle Name:
Last Name:HUAMAN
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 1:1403 MEDICAL PLAZA DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-1000
Mailing Address - Country:US
Mailing Address - Phone:407-322-0090
Mailing Address - Fax:407-321-3783
Practice Address - Street 1:1403 MEDICAL PLAZA DR
Practice Address - Street 2:SUITE 101
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-1000
Practice Address - Country:US
Practice Address - Phone:407-322-0090
Practice Address - Fax:407-321-3783
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2018-02-08
Deactivation Date:2018-01-11
Deactivation Code:
Reactivation Date:2018-02-08
Provider Licenses
StateLicense IDTaxonomies
FLME11457208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL045559800Medicaid
FLD57012Medicare UPIN