Basic Information
Provider Information | |||||||||
NPI: | 1649259623 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEEDY | ||||||||
FirstName: | DORIS | ||||||||
MiddleName: | MARGARITA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1137 | ||||||||
Address2: |   | ||||||||
City: | MELBOURNE | ||||||||
State: | FL | ||||||||
PostalCode: | 329021137 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3219529696 | ||||||||
FaxNumber: | 3219527937 | ||||||||
Practice Location | |||||||||
Address1: | 5270 BABCOCK ST NE STE 1 | ||||||||
Address2: |   | ||||||||
City: | PALM BAY | ||||||||
State: | FL | ||||||||
PostalCode: | 329054616 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3216765996 | ||||||||
FaxNumber: | 3216765926 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/10/2006 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME63747 | FL | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 2080P0205X | ME63747 | FL | N |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology |
ID Information
ID | Type | State | Issuer | Description | 372797100 | 05 | FL |   | MEDICAID | 593520087 | 01 | FL | HEALTH FIRST | OTHER | 18683 | 01 | FL | BLUE CROSS BLUE SHEILD | OTHER | 3736201002 | 01 | FL | CIGNA | OTHER | 593520087 | 01 | FL | UNITEDHEALTHCARE | OTHER | 632833 | 01 | FL | AETNA | OTHER |