Healthcare Provider Details

I. General information

NPI: 1225027592
Provider Name (Legal Business Name): KYLE R GORMEZANO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 02/19/2024
Certification Date: 02/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 PEACOCK LN N
JUPITER FL
33458-8333
US

IV. Provider business mailing address

500 PEACOCK LN N
JUPITER FL
33458-8333
US

V. Phone/Fax

Practice location:
  • Phone: 952-595-1100
  • Fax: 612-294-4903
Mailing address:
  • Phone: 561-512-9780
  • Fax: 866-611-6261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number036138160
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License NumberME77760
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD455215
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME77760
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: