Healthcare Provider Details

I. General information

NPI: 1609398916
Provider Name (Legal Business Name): LEDER RETINA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2017
Last Update Date: 04/02/2020
Certification Date: 04/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13241 BARTRAM PARK BLVD UNIT 809
JACKSONVILLE FL
32258-5216
US

IV. Provider business mailing address

332 N LOMBARDY LOOP
FRUIT COVE FL
32259-5266
US

V. Phone/Fax

Practice location:
  • Phone: 904-201-9887
  • Fax: 904-325-6434
Mailing address:
  • Phone: 203-520-7393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License NumberD64669
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207WX0108X
TaxonomyUveitis and Ocular Inflammatory Disease (Ophthalmology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberD64669
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State

VIII. Authorized Official

Name: HENRY ALEXANDER LEDER
Title or Position: OWNER
Credential: MD
Phone: 904-201-9887