Provider Demographics
NPI:1558314716
Name:LEEDY, STEPHEN A (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:A
Last Name:LEEDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 S MISSOURI AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33815-4600
Mailing Address - Country:US
Mailing Address - Phone:863-682-0027
Mailing Address - Fax:
Practice Address - Street 1:115 S MISSOURI AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33815-4600
Practice Address - Country:US
Practice Address - Phone:863-682-0027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 83980207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME 83980OtherMEDICAL LICENSE