Provider Demographics
NPI:1790294767
Name:GAITAN, ANIBAL ANTONIO (SA-C)
Entity Type:Individual
Prefix:
First Name:ANIBAL
Middle Name:ANTONIO
Last Name:GAITAN
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6195 W 19TH AVE APT 304A
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-6079
Mailing Address - Country:US
Mailing Address - Phone:305-742-5462
Mailing Address - Fax:
Practice Address - Street 1:1995 E OAKLAND PARK BLVD STE 250
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33306-1149
Practice Address - Country:US
Practice Address - Phone:954-791-6146
Practice Address - Fax:954-337-2733
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL17-526246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant