Basic Information
| Provider Information | |||||||||
| NPI: | 1043242316 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEAL | ||||||||
| FirstName: | MANUEL | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 63069 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294193069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008312402 | ||||||||
| FaxNumber: | 7706669514 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 SW 1ST AVE | ||||||||
| Address2: | DEPT OF PATHOLOGY | ||||||||
| City: | OCALA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 344744004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523517200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 08/06/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZF0201X | ME54199 | FL | Y | Allopathic & Osteopathic Physicians | Pathology | Forensic Pathology |
ID Information
| ID | Type | State | Issuer | Description | 370059300 | 05 | FL | MEDICAID |