Provider Demographics
NPI:1306242805
Name:GONZALEZ MAREY, ODALYS
Entity type:Individual
Prefix:
First Name:ODALYS
Middle Name:
Last Name:GONZALEZ MAREY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ODALYS
Other - Middle Name:MARIA
Other - Last Name:GONZALEZ MAREY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:25 NW 57TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-4802
Mailing Address - Country:US
Mailing Address - Phone:305-728-4823
Mailing Address - Fax:855-740-1524
Practice Address - Street 1:25 NW 57TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-4802
Practice Address - Country:US
Practice Address - Phone:305-728-4823
Practice Address - Fax:855-740-1524
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-10
Last Update Date:2021-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR18932208D00000X
FLACN665208D00000X
FLME143400208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice