Provider Demographics
NPI:1073617585
Name:LEAKE, DEIRDRE (MD)
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:
Last Name:LEAKE
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 1:15280 NW 79TH CT STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-5873
Mailing Address - Country:US
Mailing Address - Phone:305-558-3724
Mailing Address - Fax:786-907-4485
Practice Address - Street 1:1750 TREE BLVD
Practice Address - Street 2:SUITE 10
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-5715
Practice Address - Country:US
Practice Address - Phone:904-810-5434
Practice Address - Fax:904-810-5282
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91018207Y00000X, 207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00255496OtherRAILROAD MEDICARE
FLL56433Medicare UPIN
FLP00255496OtherRAILROAD MEDICARE