Provider Demographics
NPI:1851302020
Name:EDELSBERG, LEO (OD)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:
Last Name:EDELSBERG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19575 BISCAYNE BLVD
Mailing Address - Street 2:# 579
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-2325
Mailing Address - Country:US
Mailing Address - Phone:305-935-2999
Mailing Address - Fax:305-933-8338
Practice Address - Street 1:19575 BISCAYNE BLVD
Practice Address - Street 2:# 579
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-2325
Practice Address - Country:US
Practice Address - Phone:305-935-2999
Practice Address - Fax:305-933-8338
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1830152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19594Medicare ID - Type Unspecified