Provider Demographics
NPI:1770340127
Name:GONZALEZ, EXXON A
Entity type:Individual
Prefix:
First Name:EXXON
Middle Name:A
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11620 SW 185TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33157-6518
Mailing Address - Country:US
Mailing Address - Phone:786-972-6363
Mailing Address - Fax:
Practice Address - Street 1:11620 SW 185TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-6518
Practice Address - Country:US
Practice Address - Phone:786-972-6363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-04
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-331044106S00000X
FL223487246ZN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No246ZN0300XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherNephrology