Provider Demographics
NPI:1922007764
Name:LECLERCQ, BAUDOUIN (MD)
Entity Type:Individual
Prefix:
First Name:BAUDOUIN
Middle Name:
Last Name:LECLERCQ
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 1:2810 W SAINT ISABEL ST STE 102
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6375
Mailing Address - Country:US
Mailing Address - Phone:813-872-8480
Mailing Address - Fax:813-872-8579
Practice Address - Street 1:2810 W SAINT ISABEL ST STE 102
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6375
Practice Address - Country:US
Practice Address - Phone:813-872-8480
Practice Address - Fax:813-872-8579
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2019-01-02
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
FLME81654207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL260633000Medicaid
FLP00150829OtherRRMC (IND)
FLCD4677OtherRRMC (GRP)
FLCD4677OtherRRMC (GRP)
FL58559Medicare PIN