Healthcare Provider Details

I. General information

NPI: 1710057815
Provider Name (Legal Business Name): LEONARD A SUDBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 10/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13940 N US HIGHWAY 441 STE 102
LADY LAKE FL
32159-8909
US

IV. Provider business mailing address

601 S HARBOUR ISLAND BLVD STE 213
TAMPA FL
33602-5925
US

V. Phone/Fax

Practice location:
  • Phone: 352-751-9900
  • Fax: 844-388-6186
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME123372
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: