Provider Demographics
NPI:1285732164
Name:DE QUESADA, GONZALO (MD)
Entity type:Individual
Prefix:DR
First Name:GONZALO
Middle Name:
Last Name:DE QUESADA
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:SOUTH DADE NEONATOLOGY
Mailing Address - Street 2:215 GRAND AVENUE
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33133-4841
Mailing Address - Country:US
Mailing Address - Phone:305-441-7179
Mailing Address - Fax:305-448-7134
Practice Address - Street 1:SOUTH DADE NEONATOLOGY
Practice Address - Street 2:215 GRAND AVENUE
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33133-4841
Practice Address - Country:US
Practice Address - Phone:305-441-7179
Practice Address - Fax:305-448-7134
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 13221208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL049834300Medicaid
FL13124Medicare ID - Type Unspecified