Provider Demographics
NPI:1124649561
Name:GONZALEZ, SCARLET BENILDE
Entity type:Individual
Prefix:
First Name:SCARLET
Middle Name:BENILDE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 BLACKSTONE LANDING DR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34758-1706
Mailing Address - Country:US
Mailing Address - Phone:407-961-9782
Mailing Address - Fax:
Practice Address - Street 1:9300 SW 72ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-3205
Practice Address - Country:US
Practice Address - Phone:305-330-4959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-27
Last Update Date:2022-01-25
Deactivation Date:2021-08-23
Deactivation Code:
Reactivation Date:2021-10-18
Provider Licenses
StateLicense IDTaxonomies
FL21-495246ZC0007X
NJNJDCATEMP-015047207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Multi-Specialty