Provider Demographics
NPI:1326007139
Name:SPILLERT, LEONARD JOEL (MD)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:JOEL
Last Name:SPILLERT
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 1:4217 BAYMEADOWS RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-4676
Mailing Address - Country:US
Mailing Address - Phone:904-332-7431
Mailing Address - Fax:904-332-7408
Practice Address - Street 1:4217 BAYMEADOWS RD
Practice Address - Street 2:SUITE 3
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-4676
Practice Address - Country:US
Practice Address - Phone:904-332-7431
Practice Address - Fax:904-332-7408
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-21
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME17473208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL71614OtherBCBS
FL71614OtherBCBS
FL71614AMedicare PIN