Provider Demographics
NPI:1154323640
Name:GONZALEZ, MIGUEL ANGEL (MD)
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ANGEL
Last Name: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 1:401 SE 16TH ST
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-2529
Mailing Address - Country:US
Mailing Address - Phone:954-523-8108
Mailing Address - Fax:954-525-9282
Practice Address - Street 1:401 SE 16TH ST
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2529
Practice Address - Country:US
Practice Address - Phone:954-523-8108
Practice Address - Fax:954-525-9828
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME24288207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL035917300Medicaid
D86258Medicare UPIN
FL035917300Medicaid