Provider Demographics
NPI:1710057815
Name:SUDBERG, LEONARD A (MD)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:A
Last Name:SUDBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 S HARBOUR ISLAND BLVD STE 213
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-5925
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13940 N US HIGHWAY 441 STE 102
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159-8909
Practice Address - Country:US
Practice Address - Phone:352-751-9900
Practice Address - Fax:844-388-6186
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME123372207R00000X
NY146646207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00693792Medicaid
NY00693792Medicaid
NY00693792Medicaid
B17031Medicare UPIN