Provider Demographics
NPI:1790820603
Name:JORGE J LEAL MD UROLOGIST LLC
Entity Type:Organization
Organization Name:JORGE J LEAL MD UROLOGIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-452-2563
Mailing Address - Street 1:825 N COURTENAY PKWY
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4652
Mailing Address - Country:US
Mailing Address - Phone:321-452-2563
Mailing Address - Fax:321-453-5841
Practice Address - Street 1:825 N COURTENAY PKWY
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4652
Practice Address - Country:US
Practice Address - Phone:321-452-2563
Practice Address - Fax:321-453-5841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME29037208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL05400OtherBLUE CROSS BLUE SHIELD
4104040OtherAETNA
1653673OtherCIGNA
406142183OtherRAIL ROAD MEDICARE
406142183OtherRAIL ROAD MEDICARE
1653673OtherCIGNA