Provider Demographics
NPI:1255928776
Name:LEON GALLARDO, LEONARDO
Entity type:Individual
Prefix:
First Name:LEONARDO
Middle Name:
Last Name:LEON GALLARDO
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 1:11055 SW 186TH ST
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-6840
Mailing Address - Country:US
Mailing Address - Phone:305-964-5089
Mailing Address - Fax:305-964-5092
Practice Address - Street 1:11055 SW 186TH ST
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-6840
Practice Address - Country:US
Practice Address - Phone:305-964-5089
Practice Address - Fax:305-964-5092
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-30
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME110249207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL83-3760285Medicaid