Basic Information
| Provider Information | |||||||||
| NPI: | 1710057815 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SUDBERG | ||||||||
| FirstName: | LEONARD | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 S HARBOUR ISLAND BLVD STE 213 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336025925 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 13940 N US HIGHWAY 441 STE 102 | ||||||||
| Address2: | |||||||||
| City: | LADY LAKE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321598909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527519900 | ||||||||
| FaxNumber: | 8443886186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 10/16/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME123372 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00693792 | 05 | NY | MEDICAID |