Provider Demographics
NPI:1992966493
Name:GOMEZ LEONARDELLI, DOMINIC THEODORE (MD)
Entity type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:THEODORE
Last Name:GOMEZ LEONARDELLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2924 NIGHT WATCH WAY
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:CA
Mailing Address - Zip Code:91901-4115
Mailing Address - Country:US
Mailing Address - Phone:719-671-9277
Mailing Address - Fax:
Practice Address - Street 1:225000 HUMMINGBIRD RD STE 100
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-2950
Practice Address - Country:US
Practice Address - Phone:715-359-6442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-18
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
AZ55350207X00000X
WI53408-20207X00000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No171000000XOther Service ProvidersMilitary Health Care Provider
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery