Healthcare Provider Details

I. General information

NPI: 1881843860
Provider Name (Legal Business Name): KEILA THAMAR TOSADO DE LEON M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2008
Last Update Date: 06/02/2023
Certification Date: 06/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4729 US HIGHWAY 98 S STE 201
LAKELAND FL
33812-4336
US

IV. Provider business mailing address

6675 WESTWOOD BLVD STE 475
ORLANDO FL
32821-6027
US

V. Phone/Fax

Practice location:
  • Phone: 863-646-9663
  • Fax: 863-646-9664
Mailing address:
  • Phone: 407-845-0330
  • Fax: 888-972-1752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberACN483
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number17316
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN483
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: