Healthcare Provider Details

I. General information

NPI: 1033318928
Provider Name (Legal Business Name): GEORGE GLENN LE-BERT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 S 18TH ST STE 202
FERNANDINA BEACH FL
32034-4729
US

IV. Provider business mailing address

PO BOX 746652
ATLANTA GA
30374-6652
US

V. Phone/Fax

Practice location:
  • Phone: 904-261-9786
  • Fax: 904-376-3203
Mailing address:
  • Phone: 904-202-2092
  • Fax: 904-376-4075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberOS10063
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License NumberOS10063
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: