Provider Demographics
NPI:1205039997
Name:GORDIAN, AMPARO LEILAH (MD)
Entity Type:Individual
Prefix:
First Name:AMPARO
Middle Name:LEILAH
Last Name:GORDIAN
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 1:1945 VERSAILLES ST
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-6900
Mailing Address - Country:US
Mailing Address - Phone:941-365-0770
Mailing Address - Fax:
Practice Address - Street 1:1945 VERSAILLES ST
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-6900
Practice Address - Country:US
Practice Address - Phone:941-365-0770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2022-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101241507207RR0500X
MA239029207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110026743AMedicaid
MA110026743AMedicaid