Provider Demographics
NPI:1437130002
Name:IRAVEDRA, GONZALO J (MD)
Entity Type:Individual
Prefix:DR
First Name:GONZALO
Middle Name:J
Last Name:IRAVEDRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15757 PINES BLVD
Mailing Address - Street 2:SUITE 395
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33027-1207
Mailing Address - Country:US
Mailing Address - Phone:954-475-5500
Mailing Address - Fax:954-625-8771
Practice Address - Street 1:15757 PINES BLVD
Practice Address - Street 2:SUITE 395
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-1207
Practice Address - Country:US
Practice Address - Phone:954-475-5500
Practice Address - Fax:954-625-8771
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME67428207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251547400Medicaid
32736OtherBCBS
F83094Medicare UPIN
FL251547400Medicaid