Provider Demographics
NPI:1558632646
Name:BLANCA NELIDA GONZALEZ MD PA
Entity Type:Organization
Organization Name:BLANCA NELIDA GONZALEZ MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BLANCA
Authorized Official - Middle Name:N
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:786-218-7863
Mailing Address - Street 1:1435 W 49TH PL STE 701
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-3158
Mailing Address - Country:US
Mailing Address - Phone:786-218-7863
Mailing Address - Fax:866-557-6953
Practice Address - Street 1:1435 W 49TH PL STE 701
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3158
Practice Address - Country:US
Practice Address - Phone:786-218-7863
Practice Address - Fax:866-557-6953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-20
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME106369208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty