Provider Demographics
NPI:1831623644
Name:ROBERTI GONZALEZ, JOSE MANUEL (RSA/SA-C)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:MANUEL
Last Name:ROBERTI GONZALEZ
Suffix:
Gender:M
Credentials:RSA/SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21341 WINDY HILL DR
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:60423-8621
Mailing Address - Country:US
Mailing Address - Phone:786-252-2679
Mailing Address - Fax:
Practice Address - Street 1:21341 WINDY HILL DR
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-8621
Practice Address - Country:US
Practice Address - Phone:786-252-2679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238.000556246ZC0007X
363AS0400X
FL17-212246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL238.000556OtherIDFPR