Healthcare Provider Details

I. General information

NPI: 1417223157
Provider Name (Legal Business Name): ADAM LEO SPAIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 06/01/2023
Certification Date: 06/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N LAKEMONT AVE
WINTER PARK FL
32792-3273
US

IV. Provider business mailing address

200 N LAKEMONT AVE
WINTER PARK FL
32792-3273
US

V. Phone/Fax

Practice location:
  • Phone: 407-646-7812
  • Fax:
Mailing address:
  • Phone: 407-646-7812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301505102
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number4301505102
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME161277
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: