Healthcare Provider Details

I. General information

NPI: 1770715047
Provider Name (Legal Business Name): DORA A GAXIOLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2009
Last Update Date: 06/05/2022
Certification Date: 06/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FLORIDA DEPARTMENT OF CORRECTIONS, DADE C I 19000 SE 377TH ST
FLORIDA CITY FL
33034
US

IV. Provider business mailing address

10527 NW 8TH ST
PEMBROKE PINES FL
33026
US

V. Phone/Fax

Practice location:
  • Phone: 786-349-2364
  • Fax:
Mailing address:
  • Phone: 305-562-8809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number17667
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code261QP2400X
TaxonomyPrison Health Clinic/Center
License NumberACN380
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN380
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: