Healthcare Provider Details

I. General information

NPI: 1376621888
Provider Name (Legal Business Name): MARK G LEITNER DPM PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 09/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 BUCKINGHAM PL SUITE 101
BRANDON FL
33511-4910
US

IV. Provider business mailing address

206 BUCKINGHAM PL SUITE 101
BRANDON FL
33511-4910
US

V. Phone/Fax

Practice location:
  • Phone: 813-571-2977
  • Fax: 813-654-9545
Mailing address:
  • Phone: 813-571-2977
  • Fax: 813-654-9545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO3199
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO3199
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO2569
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPO3199
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPO2569
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberPO3199
License Number StateFL
# 7
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberPO2569
License Number StateFL
# 8
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO2569
License Number StateFL

VIII. Authorized Official

Name: DR. MARK G LEITNER
Title or Position: MEDICAL DIRECTOR
Credential: DPM
Phone: 813-571-2977