Basic Information
| Provider Information | |||||||||
| NPI: | 1285621318 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEEDY | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2400 STATE ROAD 415 | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073670923 | ||||||||
| FaxNumber: | 4073225309 | ||||||||
| Practice Location | |||||||||
| Address1: | 5449 S SEMORAN BLVD | ||||||||
| Address2: | SUITE 14 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328221722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073670923 | ||||||||
| FaxNumber: | 4073225309 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 09/30/2011 | ||||||||
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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 | 207Q00000X | OS07678 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207QA0000X | 340015002 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 220808 | 01 | FL | AMERIGROUP | OTHER | 254952200 | 05 | FL | MEDICAID | 192902 | 01 | FL | WELLCARE | OTHER |