1427043785 NPI number — GABRIEL DOMENECH MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427043785 NPI number — GABRIEL DOMENECH MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

DOMENECH

Provider First Name:

GABRIEL

Provider Middle Name:

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

DOMENECH

Provider Other First Name:

GABRIEL

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

MD

Provider Other Last Name Type Code:

2

NPI Number:

1427043785

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

05/03/2017

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

2234 COLONIAL BLVD

Provider Second Line Business Mailing Address:

ATTN: PAYER CONTRACTING & RELATIONS DEPT.

Provider Business Mailing Address City Name:

FORT MYERS

Provider Business Mailing Address State Name:

FL

Provider Business Mailing Address Postal Code:

33907-1412

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

239-931-7342

Provider Business Mailing Address Fax Number:

239-931-7385

Provider First Line Business Practice Location Address:

12741 MIRAMAR PKWY

Provider Second Line Business Practice Location Address:

SUITE 306

Provider Business Practice Location Address City Name:

MIRAMAR

Provider Business Practice Location Address State Name:

FL

Provider Business Practice Location Address Postal Code:

33027-2903

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

954-862-5300

Provider Business Practice Location Address Fax Number:

954-499-5556

Provider Enumeration Date:

09/13/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 207RH0003X , with the licence number:  78342 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 198641 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: P1019778 . This is a "FREEDOM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 5379008 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 9781 . This is a "DIMENSION HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: P958304 . This is a "OPTIMUM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 263268 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: P01391282 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: QMP000005289550 . This is a "MOLINA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 46944 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 5733554 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: F00215771101 . This is a "UNITED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".