Provider Demographics
NPI:1659587897
Name:LEBEAU, THOMAS ANTHONY (DPM)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ANTHONY
Last Name:LEBEAU
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SAINT JOHNS MEDICAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5300
Mailing Address - Country:US
Mailing Address - Phone:904-824-0869
Mailing Address - Fax:904-826-0966
Practice Address - Street 1:1 SAINT JOHNS MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5300
Practice Address - Country:US
Practice Address - Phone:904-824-0869
Practice Address - Fax:904-826-0966
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001508213ES0103X
FLPO3385213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5184027Medicaid
MI480F37288OtherBLUE CROSS/BLUE SHIELD
MIP00408087OtherRAILROAD MEDICARE
FL001262300Medicaid
FL001262300Medicaid
MI0F37288030Medicare PIN