Provider Demographics
NPI:1679500037
Name:GONZALEZ, MARISELA (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARISELA
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7171 CORAL WAY SUITE 201
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155
Mailing Address - Country:US
Mailing Address - Phone:305-220-3700
Mailing Address - Fax:305-220-9002
Practice Address - Street 1:7171 CORAL WAY SUITE 201
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155
Practice Address - Country:US
Practice Address - Phone:305-220-3700
Practice Address - Fax:305-220-9002
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME59833208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL053060301Medicaid
FL053060301Medicaid
FLF000984Medicare UPIN