Provider Demographics
NPI:1336337690
Name:SPACE COAST UROLOGY, LLC
Entity Type:Organization
Organization Name:SPACE COAST UROLOGY, LLC
Other - Org Name:JUSTO GONZALEZ, M.D.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:UROLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTO
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-268-4693
Mailing Address - Street 1:2203 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-2577
Mailing Address - Country:US
Mailing Address - Phone:321-268-4693
Mailing Address - Fax:321-268-4696
Practice Address - Street 1:2203 GARDEN ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2577
Practice Address - Country:US
Practice Address - Phone:321-268-4693
Practice Address - Fax:321-268-4696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-11
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67177174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL271696800Medicaid
FL271696800Medicaid
FLK7029Medicare PIN