MEDICARE: IKER LEYCEGUI-GARDOQUI MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	ME 95881	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AB628Y	OTHER	FL	MEDICARE PTAN
3	CU246A	OTHER	FL	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568556546
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IKER LEYCEGUI-GARDOQUI MD

Provider Business Mailing Address
First Line	:	145 NW CENTRAL PARK PLZ
Second Line	:	SUITE 101
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34986-2482
Country	:	US
Telephone Number	:	772-873-1919
Fax Number	:	772-873-1171

Provider Business Practice Location Address
First Line	:	145 NW CENTRAL PARK PLZ
Second Line	:	SUITE 101
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34986-2482
Country	:	US
Telephone Number	:	772-873-1919
Fax Number	:	772-873-1171

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	03/31/2015

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Directions to “ IKER LEYCEGUI-GARDOQUI MD” Practice Location

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