Provider Demographics
NPI:1679700694
Name:MUGO, LEAH (MD)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:MUGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 863407
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3407
Mailing Address - Country:US
Mailing Address - Phone:941-917-2600
Mailing Address - Fax:941-917-7884
Practice Address - Street 1:2345 BOBCAT VILLAGE CENTER RD
Practice Address - Street 2:SUITE202
Practice Address - City:NORTH PORT
Practice Address - State:FL
Practice Address - Zip Code:34288-8999
Practice Address - Country:US
Practice Address - Phone:941-257-2930
Practice Address - Fax:941-257-2923
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036130917207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL33181OtherBCBS FLORIDA