Provider Demographics
NPI:1053437442
Name:GONZALEZ, JUAN MANUEL
Entity type:Individual
Prefix:MR
First Name:JUAN
Middle Name:MANUEL
Last Name:GONZALEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2274 W 74TH ST
Mailing Address - Street 2:APT. 201
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-6838
Mailing Address - Country:US
Mailing Address - Phone:305-282-8554
Mailing Address - Fax:
Practice Address - Street 1:3750 W 16TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-4654
Practice Address - Country:US
Practice Address - Phone:305-822-2351
Practice Address - Fax:305-822-2392
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPH22465183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist