Provider Demographics
NPI:1154373694
Name:CARRASQUILLA, IVAN GONZALO (MD)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:GONZALO
Last Name:CARRASQUILLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:370 MINORCA AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-4330
Mailing Address - Country:US
Mailing Address - Phone:305-443-3001
Mailing Address - Fax:786-235-8575
Practice Address - Street 1:370 MINORCA AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-4330
Practice Address - Country:US
Practice Address - Phone:305-443-3001
Practice Address - Fax:786-235-8575
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69480207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101545OtherHUMANA
FL28437WMedicare ID - Type Unspecified
FL108563OtherUNITED
FLME0069480OtherLICENSE
FL28437OtherBCBS
FL39538OtherNHP
FLG83803Medicare UPIN
FL9832989OtherCIGNA
FL2648091OtherAETNA
FL282075OtherAVMED
FL379704000Medicaid