Provider Demographics
NPI:1740450568
Name:OGLIASTRI, GONZALO ALBERTO (LM T MA41976)
Entity type:Individual
Prefix:MR
First Name:GONZALO
Middle Name:ALBERTO
Last Name:OGLIASTRI
Suffix:
Gender:M
Credentials:LM T MA41976
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16773 HEMINGWAY DR
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326-3108
Mailing Address - Country:US
Mailing Address - Phone:954-588-5021
Mailing Address - Fax:
Practice Address - Street 1:16773 HEMINGWAY DR
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-3108
Practice Address - Country:US
Practice Address - Phone:954-588-5021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 41976174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA 41976OtherFL. MASSAGE LIC