Healthcare Provider Details

I. General information

NPI: 1467470237
Provider Name (Legal Business Name): LOUIS GOMBKOTO PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 SW 1ST AVE
OCALA FL
34474-4004
US

IV. Provider business mailing address

7101 W ANTHONY RD #89
OCALA FL
34479-1300
US

V. Phone/Fax

Practice location:
  • Phone: 352-351-3407
  • Fax: 352-351-3407
Mailing address:
  • Phone: 305-321-6142
  • Fax: 727-507-3618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9103606
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: