Provider Demographics
NPI:1568556546
Name:LEYCEGUI-GARDOQUI, IKER (MD)
Entity Type:Individual
Prefix:
First Name:IKER
Middle Name:
Last Name:LEYCEGUI-GARDOQUI
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 1:145 NW CENTRAL PARK PLZ
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-2482
Mailing Address - Country:US
Mailing Address - Phone:772-873-1919
Mailing Address - Fax:772-873-1171
Practice Address - Street 1:145 NW CENTRAL PARK PLZ
Practice Address - Street 2:SUITE 101
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2482
Practice Address - Country:US
Practice Address - Phone:772-873-1919
Practice Address - Fax:772-873-1171
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 95881207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAB628YOtherMEDICARE PTAN
FL277512300Medicaid
FLCU246AOtherMEDICARE PTAN