Healthcare Provider Details

I. General information

NPI: 1538246863
Provider Name (Legal Business Name): DRS PAUL AND SHIRLEY LEADEM PA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 04/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 TREE BOULEVARD SUITE 112
ST AUGUSTINE FL
32084-5774
US

IV. Provider business mailing address

1740 TREE BLVD SUITE 112
ST AUGUSTINE FL
32084-5774
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-6591
  • Fax:
Mailing address:
  • Phone: 904-829-6591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. PAUL J LEADEM JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 904-829-6591