Healthcare Provider Details

I. General information

NPI: 1255933115
Provider Name (Legal Business Name): LEODEZ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2020
Last Update Date: 11/14/2020
Certification Date: 11/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4292 CHAMBLEE TUCKER RD
TUCKER GA
30084-2103
US

IV. Provider business mailing address

3899 GRASSLAND LOOP
LAKE MARY FL
32746-4120
US

V. Phone/Fax

Practice location:
  • Phone: 770-718-1517
  • Fax:
Mailing address:
  • Phone: 407-394-2645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BYRON OSWALDO MATA
Title or Position: OWNER
Credential: MD
Phone: 786-427-4450