Provider Demographics
NPI:1871581249
Name:GONZALEZ, RAQUEL M (MD)
Entity type:Individual
Prefix:
First Name:RAQUEL
Middle Name:M
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5801 MIAMI LAKES DR E
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-2401
Mailing Address - Country:US
Mailing Address - Phone:305-821-9115
Mailing Address - Fax:
Practice Address - Street 1:5385 NE 2ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33137-2707
Practice Address - Country:US
Practice Address - Phone:305-756-9977
Practice Address - Fax:305-756-5757
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0060686208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253491600Medicaid
FL253491600Medicaid
E6006ZMedicare ID - Type Unspecified
E6006YMedicare ID - Type Unspecified