Provider Demographics
NPI:1588601751
Name:LEONHARDT, TRACIE JEAN (DO)
Entity type:Individual
Prefix:
First Name:TRACIE
Middle Name:JEAN
Last Name:LEONHARDT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 BELCHER RD S
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33771-3315
Mailing Address - Country:US
Mailing Address - Phone:727-826-0838
Mailing Address - Fax:
Practice Address - Street 1:1120 BELCHER RD S
Practice Address - Street 2:SUITE 2
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33771-3315
Practice Address - Country:US
Practice Address - Phone:727-826-0838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS6672207P00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F87045Medicare UPIN