Provider Demographics
NPI:1598709917
Name:LEON, GUSTAVO G (MD)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:G
Last Name:LEON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:7100 PINES BLVD
Mailing Address - Street 2:SUITE 23
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-7355
Mailing Address - Country:US
Mailing Address - Phone:954-967-0107
Mailing Address - Fax:954-967-0109
Practice Address - Street 1:351 NW 42ND AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-5683
Practice Address - Country:US
Practice Address - Phone:305-642-1246
Practice Address - Fax:305-631-1419
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2015-04-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME 29633208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL065358600Medicaid
FL95685XMedicare PIN
FLD78932Medicare UPIN