Provider Demographics
NPI:1255152153
Name:DE LEON, GABRIEL
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:DE LEON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:URB SABANA GARDENS CALLE 15 #2123
Mailing Address - Street 2:APT 1
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00983
Mailing Address - Country:US
Mailing Address - Phone:787-604-9257
Mailing Address - Fax:
Practice Address - Street 1:3300 S. UNIVERSITY DRIVE
Practice Address - Street 2:BROWARD
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33328
Practice Address - Country:US
Practice Address - Phone:800-541-6682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-23
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPSI47435390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program