Provider Demographics
NPI:1336130335
Name:MCLEOD, SAMUEL L III (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:L
Last Name:MCLEOD
Suffix:III
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 1:2931 CULLEN LAKE SHORE DR.
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32812
Mailing Address - Country:US
Mailing Address - Phone:407-616-3404
Mailing Address - Fax:407-857-7277
Practice Address - Street 1:2931 CULLEN LAKE SHORE DR.
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32812
Practice Address - Country:US
Practice Address - Phone:407-616-3404
Practice Address - Fax:407-857-7277
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME39837207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL47623YMedicare PIN
FL47623AMedicare PIN
D55121Medicare UPIN