Provider Demographics
NPI:1255699534
Name:GOMEZ, LESLIE ANNE (DO)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANNE
Last Name:GOMEZ
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-24
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS13339207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015528200Medicaid
FL150Z4OtherFL BLUE
FLIJ051ZMedicare PIN