1174781769 NPI number — MARK G LEITNER DPM PA

Table of content: (NPI 1174781769)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174781769 NPI number — MARK G LEITNER DPM PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARK G LEITNER DPM PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ADVANCED FOOT AND ANKLE SPECIALISTS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174781769
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
206 BUCKINGHAM PL
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
BRANDON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33511-4910
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-657-9669
Provider Business Mailing Address Fax Number:
813-654-9545

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15511 N FLORIDA AVE
Provider Second Line Business Practice Location Address:
SUITE B2
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33613-1263
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-963-3124
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LEITNER
Authorized Official First Name:
MARK
Authorized Official Middle Name:
G
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
813-571-2977

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  PO2569 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X , with the licence number: PO3199 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213EP1101X , with the licence number: PO2569 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213EP1101X , with the licence number: PO3199 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: PO2569 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: PO3199 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0131X , with the licence number: PO2569 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0131X , with the licence number: PO3199 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PO3199 . This is a "MEDICAL LICENSE - JOHNSON" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 340534600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 65891 . This is a "BCBS - JOHNSON" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 390319200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 65462 . This is a "BCBS - LEITNER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: DG1014 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: PO2569 . This is a "MEDICAL LICENSE - LEITNER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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