Provider Demographics
NPI:1053388512
Name:TEYTELBAUM, LEO R (MD)
Entity type:Individual
Prefix:MR
First Name:LEO
Middle Name:R
Last Name:TEYTELBAUM
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:6450 38TH AVE N
Mailing Address - Street 2:SUITE #350
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-1645
Mailing Address - Country:US
Mailing Address - Phone:727-344-7339
Mailing Address - Fax:727-343-8470
Practice Address - Street 1:6450 38TH AVE N
Practice Address - Street 2:SUITE #350
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1645
Practice Address - Country:US
Practice Address - Phone:727-344-7339
Practice Address - Fax:727-343-8470
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME0044110207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL069784200Medicaid
79904YMedicare PIN
FL069784200Medicaid