Provider Demographics
NPI:1245766237
Name:LEIBOWITZ, TODD (DO)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:LEIBOWITZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:841 PRUDENTIAL DR STE 1400
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8364
Mailing Address - Country:US
Mailing Address - Phone:904-396-5682
Mailing Address - Fax:
Practice Address - Street 1:13001 ATLANTIC BLVD STE 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-7126
Practice Address - Country:US
Practice Address - Phone:904-221-0264
Practice Address - Fax:904-390-7507
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS17020207Q00000X, 207P00000X, 207Q00000X
GA86442207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program