Provider Demographics
NPI:1679776462
Name:RAFAEL GOTTENGER MD PA
Entity Type:Organization
Organization Name:RAFAEL GOTTENGER MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:GOTTENGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-669-0900
Mailing Address - Street 1:PO BOX 431900
Mailing Address - Street 2:
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33243-1900
Mailing Address - Country:US
Mailing Address - Phone:305-669-0900
Mailing Address - Fax:305-669-0100
Practice Address - Street 1:7330 SW 62ND PL
Practice Address - Street 2:SUITE #205
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4825
Practice Address - Country:US
Practice Address - Phone:305-669-0900
Practice Address - Fax:305-669-0100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-07
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91263208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK7623Medicaid
FL272290900Medicare ID - Type Unspecified
FLK7623Medicaid