Provider Demographics
NPI:1598762395
Name:ALONZO, LESLIE R III (OD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:R
Last Name:ALONZO
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 VONDERBURG DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5982
Mailing Address - Country:US
Mailing Address - Phone:813-681-1122
Mailing Address - Fax:813-684-4924
Practice Address - Street 1:403 VONDERBURG DR
Practice Address - Street 2:STE 101
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5982
Practice Address - Country:US
Practice Address - Phone:813-681-1122
Practice Address - Fax:813-684-4924
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2323152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4388598OtherAETNA
FL6500152OtherGHI
FL078635700Medicaid
FL2074336OtherAETNA
FL19254OtherBCBS FLORIDA
FL6500152OtherGHI
GA410038426Medicare PIN
FL19254OtherBCBS FLORIDA
FL2074336OtherAETNA
FL19254XMedicare PIN