Provider Demographics
NPI:1033328968
Name:ERKONEN, GWEN E (MD)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:E
Last Name:ERKONEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GWEN
Other - Middle Name:E
Other - Last Name:WELLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3100 SW 62ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-1009
Mailing Address - Country:US
Mailing Address - Phone:305-666-6511
Mailing Address - Fax:
Practice Address - Street 1:3100 SW 62ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-3009
Practice Address - Country:US
Practice Address - Phone:305-666-6511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-7306208000000X
IA37801208000000X, 2080P0203X
FLME1463852080P0203X
IL036-1251752080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036125175Medicaid
IL256510075Medicare PIN