Provider Demographics
NPI:1538174941
Name:MARK LEEDS, D.O., P.A.
Entity type:Organization
Organization Name:MARK LEEDS, D.O., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:LEEDS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:954-776-6226
Mailing Address - Street 1:304 INDIAN TRACE #528
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326
Mailing Address - Country:US
Mailing Address - Phone:954-776-6226
Mailing Address - Fax:954-692-8120
Practice Address - Street 1:304 INDIAN TRACE #528
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326
Practice Address - Country:US
Practice Address - Phone:954-776-6226
Practice Address - Fax:954-692-8120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7559207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274554200Medicaid
FLK9490Medicare ID - Type Unspecified
FL274554200Medicaid