Provider Demographics
NPI:1518133610
Name:LEON WAYNE MITCHELL MD PA
Entity Type:Organization
Organization Name:LEON WAYNE MITCHELL MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KLAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-971-2300
Mailing Address - Street 1:3010 E 138TH AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33613-3904
Mailing Address - Country:US
Mailing Address - Phone:813-971-2300
Mailing Address - Fax:813-971-2311
Practice Address - Street 1:3010 E 138TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-3904
Practice Address - Country:US
Practice Address - Phone:813-971-2300
Practice Address - Fax:813-971-2311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME13022173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME13022OtherFL STATE LICENSE
FLD58053Medicare UPIN