Provider Demographics
NPI:1376621888
Name:MARK G LEITNER DPM PA
Entity Type:Organization
Organization Name:MARK G LEITNER DPM PA
Other - Org Name:ADVANCED FOOT AND ANKLE SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:LEITNER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:813-571-2977
Mailing Address - Street 1:206 BUCKINGHAM PL
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4910
Mailing Address - Country:US
Mailing Address - Phone:813-571-2977
Mailing Address - Fax:813-654-9545
Practice Address - Street 1:206 BUCKINGHAM PL
Practice Address - Street 2:SUITE 101
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4910
Practice Address - Country:US
Practice Address - Phone:813-571-2977
Practice Address - Fax:813-654-9545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3199213E00000X, 213EP1101X, 213ES0103X, 213ES0131X
FLPO2569213E00000X, 213EP1101X, 213ES0103X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001631400Medicaid
FLPO3199OtherMEDICAL LICENSE - JOHNSON
FL65891OtherBCBS - JOHNSON
FLDG1014OtherRAILROAD MEDICARE
FLPO2569OtherMEDICAL LICENSE - LEITNER
FL65462OtherBCBS - LEITNER
FL65462OtherBCBS - LEITNER
FLV05251Medicare UPIN
FL001631400Medicaid
FLU01289Medicare UPIN