Provider Demographics
NPI:1336220771
Name:LEOTTA, GUS JOSEPH III (MD)
Entity Type:Individual
Prefix:DR
First Name:GUS
Middle Name:JOSEPH
Last Name:LEOTTA
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:4631 N CONGRESS AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-3209
Mailing Address - Country:US
Mailing Address - Phone:561-530-1715
Mailing Address - Fax:561-530-1724
Practice Address - Street 1:4631 N CONGRESS AVE STE 203
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-3209
Practice Address - Country:US
Practice Address - Phone:561-530-1725
Practice Address - Fax:561-863-5576
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME106093207X00000X
FLME 106093207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA051347OtherGEORGIA STATE LICENSE
CAAFE 73482OtherPHYSICIAN AND SURGEON
FL007381500Medicaid
FLME 106093OtherMEDICAL BOARD OF FLORIDA
FLME 106093OtherMEDICAL BOARD OF FLORIDA