Provider Demographics
NPI:1801198791
Name:GONZALEZ PIMENTEL, LEIDEN EZEQUIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:LEIDEN
Middle Name:EZEQUIEL
Last Name:GONZALEZ PIMENTEL
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 1:5425 S FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2523
Mailing Address - Country:US
Mailing Address - Phone:863-644-3585
Mailing Address - Fax:863-644-3171
Practice Address - Street 1:5425 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2523
Practice Address - Country:US
Practice Address - Phone:863-644-3585
Practice Address - Fax:863-644-3171
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-26
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR18095208D00000X
FLACN688208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR18095OtherPR LICENSE
FLACN688OtherMEDICAL LICENSE