Basic Information
| Provider Information | |||||||||
| NPI: | 1922096437 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DORVAL | ||||||||
| FirstName: | GOLD | ||||||||
| MiddleName: | SMITH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1065 NE 125TH ST | ||||||||
| Address2: | SUITE 409 | ||||||||
| City: | NORTH MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331615821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888526672 | ||||||||
| FaxNumber: | 3058914228 | ||||||||
| Practice Location | |||||||||
| Address1: | 1065 NE 125TH ST STE 206 | ||||||||
| Address2: | |||||||||
| City: | NORTH MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888526672 | ||||||||
| FaxNumber: | 3058914228 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2005 | ||||||||
| LastUpdateDate: | 07/23/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | ME56209 | FL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 2084P0800X | ME56209 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 057539901 | 05 | FL | MEDICAID |