Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0505X | Family Doctor - Adult Medicine | ACN1189 | FL |
NPI | 1013568484 |
---|---|
Provider Name | Misael L Gongora Veliz |
First Address | Homestead, FL 33030-4350 |
Second Address | Homestead, FL 33030-4350 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/09/2019 |
Last Update Date | 10/10/2019 |