Provider Demographics
NPI:1508836552
Name:LEEDS, MARK J (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:LEEDS
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:304 INDIAN TRACE #528
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33326
Mailing Address - Country:US
Mailing Address - Phone:954-776-6226
Mailing Address - Fax:954-692-8120
Practice Address - Street 1:304 INDIAN TRACE #528
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326
Practice Address - Country:US
Practice Address - Phone:954-776-6226
Practice Address - Fax:954-692-8120
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS7559207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G78667Medicare UPIN