=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720571292
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEVEN LEONG
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2018
-----------------------------------------------------
Last Update Date | 09/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 620 10TH ST N(727) 824-3120 SUITE 1E
-----------------------------------------------------
City | ST. PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33705-2021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-824-3120
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 620 10TH ST. N SUITE 1E
-----------------------------------------------------
City | ST. PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33705-2021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | OS17455
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------