Provider Demographics
NPI:1518916287
Name:MENNEN, LEONARD (DO)
Entity Type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:
Last Name:MENNEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 W SWANN AVE
Mailing Address - Street 2:SUITE 600
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4039
Mailing Address - Country:US
Mailing Address - Phone:813-876-7073
Mailing Address - Fax:813-877-1277
Practice Address - Street 1:2605 W SWANN AVE
Practice Address - Street 2:SUITE 600
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4039
Practice Address - Country:US
Practice Address - Phone:813-876-7073
Practice Address - Fax:813-877-1277
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0003135207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251014600Medicaid
FL57414XMedicare PIN
FL251014600Medicaid