Provider Demographics
NPI:1518340942
Name:LESLIE A GOMEZ DO PA
Entity Type:Organization
Organization Name:LESLIE A GOMEZ DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:941-746-4151
Mailing Address - Street 1:250 2ND ST E
Mailing Address - Street 2:STE 3B
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-1029
Mailing Address - Country:US
Mailing Address - Phone:941-746-4151
Mailing Address - Fax:941-746-4345
Practice Address - Street 1:250 2ND ST E
Practice Address - Street 2:STE 3B
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-1029
Practice Address - Country:US
Practice Address - Phone:941-746-4151
Practice Address - Fax:941-746-4345
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-02
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015528000Medicaid
FLDW3648OtherMEDICARE RAILROAD
FL00A7GOtherFL BLUE
FLIJ046AMedicare PIN