Healthcare Provider Details

I. General information

NPI: 1659587897
Provider Name (Legal Business Name): THOMAS ANTHONY LEBEAU D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 10/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SAINT JOHNS MEDICAL PARK DR
ST AUGUSTINE FL
32086-5300
US

IV. Provider business mailing address

1 SAINT JOHNS MEDICAL PARK DR
ST AUGUSTINE FL
32086-5300
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-0869
  • Fax: 904-826-0966
Mailing address:
  • Phone: 904-824-0869
  • Fax: 904-826-0966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number5901001508
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO3385
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: