Provider Demographics
NPI:1720076144
Name:TRULLENQUE, GRETEL (DO)
Entity type:Individual
Prefix:
First Name:GRETEL
Middle Name:
Last Name:TRULLENQUE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 415033
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33141-5033
Mailing Address - Country:US
Mailing Address - Phone:305-504-6136
Mailing Address - Fax:305-448-6217
Practice Address - Street 1:1021 IVES DAIRY RD STE 214
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33179-2537
Practice Address - Country:US
Practice Address - Phone:305-504-6136
Practice Address - Fax:305-448-6217
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS8965207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL271754900Medicaid
FLI26800Medicare UPIN