1760401632 NPI number — DR. SHANNON L W CLARK LEITENBAUER OD

Table of content: DR. SHANNON L W CLARK LEITENBAUER OD (NPI 1760401632)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760401632 NPI number — DR. SHANNON L W CLARK LEITENBAUER OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEITENBAUER
Provider First Name:
SHANNON
Provider Middle Name:
L W CLARK
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLARK LEITENBAUER
Provider Other First Name:
SHANNON
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1760401632
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2305 OLEANDER BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT PIERCE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34982-5830
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-465-6616
Provider Business Mailing Address Fax Number:
772-468-2858

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2305 OLEANDER BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT PIERCE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34982-5830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-465-6616
Provider Business Practice Location Address Fax Number:
772-468-2858
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPC0003067 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 009792800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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