Healthcare Provider Details

I. General information

NPI: 1366445512
Provider Name (Legal Business Name): LEO A PEREZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: LEONCIO ANSELMO PEREZ M.D.

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 07/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8732 SOMERSWORTH PLACE
TAMPA FL
33634-1029
US

IV. Provider business mailing address

8732 SOMERSWORTH PLACE
TAMPA FL
33634-1029
US

V. Phone/Fax

Practice location:
  • Phone: 813-887-5722
  • Fax:
Mailing address:
  • Phone: 813-887-5722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME46540
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208U00000X
TaxonomyClinical Pharmacology Physician
License NumberME46540
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: