Basic Information
| Provider Information | |||||||||
| NPI: | 1881843860 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TOSADO DE LEON | ||||||||
| FirstName: | KEILA | ||||||||
| MiddleName: | THAMAR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4725 US HIGHWAY 98 S | ||||||||
| Address2: | STE 102 | ||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338124334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636469191 | ||||||||
| FaxNumber: | 8636465252 | ||||||||
| Practice Location | |||||||||
| Address1: | 4725 US HIGHWAY 98 S | ||||||||
| Address2: | STE 102 | ||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338124334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636469191 | ||||||||
| FaxNumber: | 8636465252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2008 | ||||||||
| LastUpdateDate: | 04/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ACN483 | FL | N | Allopathic & Osteopathic Physicians | Pediatrics | 208D00000X | 17316 | PR | N | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | ACN483 | FL | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | ACN483 | 01 | FL | MEDICINE DOCTOR LIC | OTHER |