Provider Demographics
NPI:1023194859
Name:LEADEM, SHIRLEY N (MD)
Entity Type:Individual
Prefix:DR
First Name:SHIRLEY
Middle Name:N
Last Name:LEADEM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 TREE BOULEVARD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-5774
Mailing Address - Country:US
Mailing Address - Phone:904-829-6591
Mailing Address - Fax:904-824-8856
Practice Address - Street 1:1740 TREE BOULEVARD
Practice Address - Street 2:SUITE 112
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-5774
Practice Address - Country:US
Practice Address - Phone:904-829-6591
Practice Address - Fax:904-824-8856
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME88076208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4049277OtherAETNA
FL377712OtherBC/BS
FL267624900Medicaid
FL377712OtherBC/BS