Provider Demographics
NPI:1659986487
Name:GONZALEZ, DAVID R (PTA, LMT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:PTA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 N 34TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-3139
Mailing Address - Country:US
Mailing Address - Phone:305-308-4817
Mailing Address - Fax:
Practice Address - Street 1:1000 W PEMBROKE RD STE 316
Practice Address - Street 2:
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-2181
Practice Address - Country:US
Practice Address - Phone:305-308-4817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA22449225200000X
FLMA33593225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant