Provider Demographics
NPI:1538631387
Name:GABOTE GARCIA, FIDEL SIMON
Entity type:Individual
Prefix:MR
First Name:FIDEL
Middle Name:SIMON
Last Name:GABOTE GARCIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4610 SW 112TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-5560
Mailing Address - Country:US
Mailing Address - Phone:786-870-2189
Mailing Address - Fax:
Practice Address - Street 1:4610 SW 112TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-5560
Practice Address - Country:US
Practice Address - Phone:786-870-2189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-18
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X
FLAPRN11028129363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020285300Medicaid