Provider Demographics
NPI:1033314190
Name:DE JESUS-GOMEZ, GUSTAVO ALBERTO (MD)
Entity Type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:ALBERTO
Last Name:DE JESUS-GOMEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1328
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33846-1328
Mailing Address - Country:US
Mailing Address - Phone:863-937-3139
Mailing Address - Fax:863-937-3147
Practice Address - Street 1:5325 US HWY 98 S
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33812-3381
Practice Address - Country:US
Practice Address - Phone:863-937-3139
Practice Address - Fax:863-937-3147
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR25992208600000X
FLME112008208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14JQ2OtherBCBS OF FLORIDA