Provider Demographics
NPI:1770715047
Name:GAXIOLA, DORA A (MD)
Entity type:Individual
Prefix:
First Name:DORA
Middle Name:A
Last Name:GAXIOLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10527 NW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026
Mailing Address - Country:US
Mailing Address - Phone:305-562-8809
Mailing Address - Fax:
Practice Address - Street 1:FLORIDA DEPARTMENT OF CORRECTIONS, DADE C I
Practice Address - Street 2:19000 SE 377TH ST
Practice Address - City:FLORIDA CITY
Practice Address - State:FL
Practice Address - Zip Code:33034
Practice Address - Country:US
Practice Address - Phone:786-349-2364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2022-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17667208D00000X
FLACN380261QP2400X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No261QP2400XAmbulatory Health Care FacilitiesClinic/CenterPrison Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRCCN:920935184829-002Medicare PIN