Provider Demographics
NPI:1679810766
Name:GONZALES, DINORAH
Entity Type:Individual
Prefix:
First Name:DINORAH
Middle Name:
Last Name:GONZALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8302 NW 103RD ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33016-4697
Mailing Address - Country:US
Mailing Address - Phone:305-456-6803
Mailing Address - Fax:
Practice Address - Street 1:8302 NW 103RD ST
Practice Address - Street 2:SUITE 202
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33016-4697
Practice Address - Country:US
Practice Address - Phone:305-456-6803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-09
Last Update Date:2013-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA62302261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service