Healthcare Provider Details

I. General information

NPI: 1073617585
Provider Name (Legal Business Name): DEIRDRE LEAKE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEIRDRE DENEE ANDERSON

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 06/12/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 TREE BLVD SUITE 10
ST AUGUSTINE FL
32084-5715
US

IV. Provider business mailing address

15280 NW 79TH CT STE 200
MIAMI LAKES FL
33016-5873
US

V. Phone/Fax

Practice location:
  • Phone: 904-810-5434
  • Fax: 904-810-5282
Mailing address:
  • Phone: 305-558-3724
  • Fax: 786-907-4485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberME91018
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberME91018
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: