Provider Demographics
NPI:1881971885
Name:CANDELARIO GONZALEZ, JUAN JOSE (MD)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:JOSE
Last Name:CANDELARIO GONZALEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11531 N 56TH ST
Mailing Address - Street 2:#103
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33617-2238
Mailing Address - Country:US
Mailing Address - Phone:813-999-4963
Mailing Address - Fax:
Practice Address - Street 1:11531 N 56TH ST
Practice Address - Street 2:#103
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33617-2238
Practice Address - Country:US
Practice Address - Phone:813-999-4963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-04
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME130303261QP2300X
PR29075390200000X
PR28732390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program