Provider Demographics
NPI:1417949140
Name:YASON, LEO VILLAR (MD)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:VILLAR
Last Name:YASON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LEO
Other - Middle Name:VILLAR
Other - Last Name:YASON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:12200 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-2630
Mailing Address - Country:US
Mailing Address - Phone:352-596-4562
Mailing Address - Fax:352-596-8188
Practice Address - Street 1:12200 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-2630
Practice Address - Country:US
Practice Address - Phone:352-596-4562
Practice Address - Fax:352-596-8188
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00564172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371658900Medicaid
FL371658900Medicaid
FL12374Medicare ID - Type Unspecified
FL12374YMedicare PIN