Provider Demographics
NPI:1518329911
Name:LANTIGUA, LEODAN SR
Entity Type:Individual
Prefix:
First Name:LEODAN
Middle Name:
Last Name:LANTIGUA
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 440846
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33144-0846
Mailing Address - Country:US
Mailing Address - Phone:305-266-7556
Mailing Address - Fax:305-266-7557
Practice Address - Street 1:960 SW 82 AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144
Practice Address - Country:US
Practice Address - Phone:305-266-7556
Practice Address - Fax:305-266-7557
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-24
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS12142208D00000X
FLHCC8713261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center