Provider Demographics
NPI:1316144074
Name:FIDALGO, GABRIEL (PT)
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:FIDALGO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3191 CORAL WAY STE 109
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33145-3219
Mailing Address - Country:US
Mailing Address - Phone:305-447-8118
Mailing Address - Fax:305-447-8114
Practice Address - Street 1:3191 CORAL WAY STE 109
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33145-3219
Practice Address - Country:US
Practice Address - Phone:305-447-8118
Practice Address - Fax:305-447-8114
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT22033174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist