Provider Demographics
NPI:1316628563
Name:LEOR, GUSTAVO
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:LEOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 E VALERIO ST APT C
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93101-1195
Mailing Address - Country:US
Mailing Address - Phone:805-284-2068
Mailing Address - Fax:
Practice Address - Street 1:300 E BELLEVUE DR APT 125
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-3105
Practice Address - Country:US
Practice Address - Phone:805-284-2068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95105960163W00000X
AZ1811497367500000X
CA95002220207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology