Provider Demographics
NPI:1568036010
Name:FUNDORA GONZALEZ, IVAN GABRIEL (MD)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:GABRIEL
Last Name:FUNDORA GONZALEZ
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 1:6801 SW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-4742
Mailing Address - Country:US
Mailing Address - Phone:855-226-6633
Mailing Address - Fax:866-285-7068
Practice Address - Street 1:6801 SW 8TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-4742
Practice Address - Country:US
Practice Address - Phone:855-226-6633
Practice Address - Fax:866-285-7068
Is Sole Proprietor?:No
Enumeration Date:2021-05-19
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLACN1463208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program