Provider Demographics
NPI:1609398916
Name:LEDER RETINA
Entity Type:Organization
Organization Name:LEDER RETINA
Other - Org Name:LEDER RETINA & UVEITIS SPECIALIST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:LEDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-201-9887
Mailing Address - Street 1:332 N LOMBARDY LOOP
Mailing Address - Street 2:
Mailing Address - City:FRUIT COVE
Mailing Address - State:FL
Mailing Address - Zip Code:32259-5266
Mailing Address - Country:US
Mailing Address - Phone:203-520-7393
Mailing Address - Fax:
Practice Address - Street 1:13241 BARTRAM PARK BLVD UNIT 809
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-5216
Practice Address - Country:US
Practice Address - Phone:904-201-9887
Practice Address - Fax:904-325-6434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-10
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207WX0107X, 207WX0108X
MDD64669261Q00000X, 261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina SpecialistGroup - Single Specialty
No207WX0108XAllopathic & Osteopathic PhysiciansOphthalmologyUveitis and Ocular Inflammatory DiseaseGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
No261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL048036300Medicaid