Provider Demographics
NPI:1780112367
Name:HERNANDEZ GONZALEZ, ROBISLEY (SAC)
Entity type:Individual
Prefix:
First Name:ROBISLEY
Middle Name:
Last Name:HERNANDEZ GONZALEZ
Suffix:
Gender:M
Credentials:SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2535 SW 11TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33135-4809
Mailing Address - Country:US
Mailing Address - Phone:786-262-3072
Mailing Address - Fax:
Practice Address - Street 1:2535 SW 11TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33135-4809
Practice Address - Country:US
Practice Address - Phone:786-262-3072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17-310246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL33050166Medicaid