Provider Demographics
NPI:1265642581
Name:GONZALEZ, FANNY (MD)
Entity type:Individual
Prefix:
First Name:FANNY
Middle Name:
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:FANNY
Other - Middle Name:
Other - Last Name:GONZALEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 144653
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33114-4653
Mailing Address - Country:US
Mailing Address - Phone:305-867-7005
Mailing Address - Fax:305-856-7533
Practice Address - Street 1:2525 SW 3RD AVE
Practice Address - Street 2:UNIT CU-1
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33129-2056
Practice Address - Country:US
Practice Address - Phone:305-856-7005
Practice Address - Fax:305-856-7533
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME106001208000000X, 2080P0210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002182200Medicaid