Provider Demographics
NPI:1215941596
Name:GONZALO J IRAVEDRA PA
Entity type:Organization
Organization Name:GONZALO J IRAVEDRA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GONZALO
Authorized Official - Middle Name:J
Authorized Official - Last Name:IRAVEDRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-499-7878
Mailing Address - Street 1:18503 PINES BLVD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-1404
Mailing Address - Country:US
Mailing Address - Phone:954-499-7878
Mailing Address - Fax:954-499-7877
Practice Address - Street 1:18503 PINES BLVD
Practice Address - Street 2:SUITE 303
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-1404
Practice Address - Country:US
Practice Address - Phone:954-499-7878
Practice Address - Fax:954-499-7877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME32736207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAA109Medicare PIN