Provider Demographics
NPI:1003258666
Name:LEESBURG PEDIATRICS PA
Entity Type:Organization
Organization Name:LEESBURG PEDIATRICS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:AFZAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-394-3929
Mailing Address - Street 1:265 CITRUS TOWER BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-1908
Mailing Address - Country:US
Mailing Address - Phone:352-394-3929
Mailing Address - Fax:352-394-6446
Practice Address - Street 1:8113 CENTRALIA CT
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34788-7508
Practice Address - Country:US
Practice Address - Phone:352-435-7938
Practice Address - Fax:352-805-4145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-24
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009585800Medicaid