Provider Demographics
NPI:1487827242
Name:REYES-GAVILAN, JULIO CESAR (MD)
Entity Type:Individual
Prefix:
First Name:JULIO
Middle Name:CESAR
Last Name:REYES-GAVILAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16015 SW 102ND LN
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-6173
Mailing Address - Country:US
Mailing Address - Phone:786-655-0095
Mailing Address - Fax:786-870-5651
Practice Address - Street 1:2240 NW 87TH AVE
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33172-2414
Practice Address - Country:US
Practice Address - Phone:786-655-0095
Practice Address - Fax:786-870-5651
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-11
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME121514208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003192100Medicaid