Provider Demographics
NPI:1750028932
Name:BRETON GAMIOTEA, RAUL (MD)
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:
Last Name:BRETON GAMIOTEA
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 1:601 S HARBOUR ISLAND BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-5925
Mailing Address - Country:US
Mailing Address - Phone:800-480-5243
Mailing Address - Fax:800-928-7449
Practice Address - Street 1:7558 CYPRESS GARDENS BLVD
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33884-3200
Practice Address - Country:US
Practice Address - Phone:863-215-6639
Practice Address - Fax:844-388-6186
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-18
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR390200000X
FLACN1534207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program