Provider Demographics
NPI:1225027592
Name:GORMEZANO, KYLE R (MD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:R
Last Name:GORMEZANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 PEACOCK LN N
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-8333
Mailing Address - Country:US
Mailing Address - Phone:561-512-9780
Mailing Address - Fax:866-611-6261
Practice Address - Street 1:500 PEACOCK LN N
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-8333
Practice Address - Country:US
Practice Address - Phone:952-595-1100
Practice Address - Fax:612-294-4903
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361381602085R0202X
FLME777602085U0001X, 2085R0202X
PAMD455215208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL256123900Medicaid
FLE2278Medicare ID - Type Unspecified
FLG89281Medicare UPIN
FLE2278Medicare PIN