Provider Demographics
NPI:1760481972
Name:LESADA, CORAZON E (MD)
Entity type:Individual
Prefix:
First Name:CORAZON
Middle Name:E
Last Name:LESADA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8049 ARLINGTON EXPY
Mailing Address - Street 2:SUITE 4
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-6269
Mailing Address - Country:US
Mailing Address - Phone:904-721-2670
Mailing Address - Fax:904-721-2670
Practice Address - Street 1:8049 ARLINGTON EXPY
Practice Address - Street 2:SUITE 4
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-6269
Practice Address - Country:US
Practice Address - Phone:904-721-2670
Practice Address - Fax:904-721-2670
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME24383174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD53109Medicare UPIN
FL16954Medicare ID - Type Unspecified