Provider Demographics
NPI:1093964819
Name:OQUENDO, GUALBERTO (MD)
Entity Type:Individual
Prefix:
First Name:GUALBERTO
Middle Name:
Last Name:OQUENDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GUALBERTO
Other - Middle Name:
Other - Last Name:OQUENDO-ROMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:720 ALMOND ST
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-3124
Mailing Address - Country:US
Mailing Address - Phone:352-404-6959
Mailing Address - Fax:352-404-6960
Practice Address - Street 1:720 ALMOND ST
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-3124
Practice Address - Country:US
Practice Address - Phone:352-404-6959
Practice Address - Fax:352-404-6960
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-17
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL114521208100000X
PR18433208100000X
FLME114521208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007737500Medicaid
FL007737500Medicaid