Provider Demographics
NPI:1578759197
Name:GONZALEZ, NELSON (MD)
Entity Type:Individual
Prefix:DR
First Name:NELSON
Middle Name:
Last Name: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 1:15753 SW 140TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-6714
Mailing Address - Country:US
Mailing Address - Phone:305-431-6957
Mailing Address - Fax:
Practice Address - Street 1:11045 SW 216 ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33170
Practice Address - Country:US
Practice Address - Phone:786-429-1639
Practice Address - Fax:786-883-0900
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-18
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME101417207Q00000X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110070100Medicaid