Provider Demographics
NPI:1912330416
Name:GULF COAST SURGICAL ONCOLOGY PL
Entity Type:Organization
Organization Name:GULF COAST SURGICAL ONCOLOGY PL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEONARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLEGAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-293-6979
Mailing Address - Street 1:730 BAYFRONT PKWY STE 5A
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32502-6250
Mailing Address - Country:US
Mailing Address - Phone:850-432-5488
Mailing Address - Fax:850-432-5228
Practice Address - Street 1:730 BAYFRONT PKWY STE 5A
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32502-6250
Practice Address - Country:US
Practice Address - Phone:850-432-5488
Practice Address - Fax:850-432-5228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-20
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009686800Medicaid