Provider Demographics
NPI:1629028865
Name:ULTRA MEDICAL CENTER, CORP
Entity Type:Organization
Organization Name:ULTRA MEDICAL CENTER, CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:N
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-644-7407
Mailing Address - Street 1:711 NW 23RD AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33125-3298
Mailing Address - Country:US
Mailing Address - Phone:305-644-7407
Mailing Address - Fax:305-644-7408
Practice Address - Street 1:711 NW 23RD AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33125-3298
Practice Address - Country:US
Practice Address - Phone:305-644-7407
Practice Address - Fax:305-644-7408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL136410067207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty