Healthcare Provider Details

I. General information

NPI: 1740271642
Provider Name (Legal Business Name): LEANN J. MANDESE O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2194 A1A HWY SUITE 109
INDIAN HARBOUR BEACH FL
32937-4930
US

IV. Provider business mailing address

2194 HIGHWAY A1A STE 109-110
INDIAN HARBOUR BEACH FL
32937-4930
US

V. Phone/Fax

Practice location:
  • Phone: 321-777-1670
  • Fax: 321-773-0187
Mailing address:
  • Phone: 321-777-1670
  • Fax: 321-773-0187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOP3125
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: