Provider Demographics
NPI:1275628455
Name:LEASEBURGE, LORI A (MD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:A
Last Name:LEASEBURGE
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 1:1891 BEACH BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32250-2644
Mailing Address - Country:US
Mailing Address - Phone:904-249-3743
Mailing Address - Fax:904-249-2047
Practice Address - Street 1:1891 BEACH BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32250-2644
Practice Address - Country:US
Practice Address - Phone:904-249-3743
Practice Address - Fax:904-249-2047
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93918207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273607100Medicaid
FL273607100Medicaid
FL18808YMedicare PIN