Basic Information
| Provider Information | |||||||||
| NPI: | 1225027592 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORMEZANO | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 PEACOCK LN N | ||||||||
| Address2: | |||||||||
| City: | JUPITER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334588333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5615129780 | ||||||||
| FaxNumber: | 8666116261 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 PEACOCK LN N | ||||||||
| Address2: | |||||||||
| City: | JUPITER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334588333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525951100 | ||||||||
| FaxNumber: | 6122944903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 12/29/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085U0001X | ME77760 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | 208D00000X | MD455215 | PA | N | Allopathic & Osteopathic Physicians | General Practice | 2085R0202X | ME77760 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.