Provider Demographics
NPI:1174511554
Name:MANDINA, LEONARDO (MD)
Entity Type:Individual
Prefix:
First Name:LEONARDO
Middle Name:
Last Name:MANDINA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 E CAUSEWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32963-2234
Mailing Address - Country:US
Mailing Address - Phone:772-231-3777
Mailing Address - Fax:772-231-1202
Practice Address - Street 1:908 E CAUSEWAY BLVD
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32963-2234
Practice Address - Country:US
Practice Address - Phone:772-231-3777
Practice Address - Fax:772-231-1202
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 0044922207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
31177OtherBCBS
D54249Medicare UPIN
31177Medicare ID - Type Unspecified