Healthcare Provider Details

I. General information

NPI: 1922007764
Provider Name (Legal Business Name): BAUDOUIN LECLERCQ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 01/02/2019
Certification Date:
Deactivation Date: 03/17/2006
Reactivation Date: 03/31/2006

III. Provider practice location address

2810 W SAINT ISABEL ST STE 102
TAMPA FL
33607-6375
US

IV. Provider business mailing address

2810 W SAINT ISABEL ST STE 102
TAMPA FL
33607-6375
US

V. Phone/Fax

Practice location:
  • Phone: 813-872-8480
  • Fax: 813-872-8579
Mailing address:
  • Phone: 813-872-8480
  • Fax: 813-872-8579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberME81654
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: