Provider Demographics
NPI:1427043785
Name:DOMENECH, GABRIEL (MD)
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:DOMENECH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GABRIEL
Other - Middle Name:
Other - Last Name:DOMENECH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:12741 MIRAMAR PKWY
Practice Address - Street 2:SUITE 306
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-2903
Practice Address - Country:US
Practice Address - Phone:954-862-5300
Practice Address - Fax:954-499-5556
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL78342207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL198641OtherWELLCARE
FLP1019778OtherFREEDOM
FL5379008OtherCIGNA
FL9781OtherDIMENSION HEALTH
FLP958304OtherOPTIMUM
FL263268OtherAVMED
FLP01391282OtherRR MEDICARE
FLQMP000005289550OtherMOLINA
FL46944OtherBCBS
FL5733554OtherAETNA
FLF00215771101OtherUNITED
FL46944VMedicare PIN
FLP01391282OtherRR MEDICARE
FLQMP000005289550OtherMOLINA
FL5379008OtherCIGNA