Provider Demographics
NPI:1356508410
Name:BLACKWELL, LEA MOREEN (MD)
Entity type:Individual
Prefix:
First Name:LEA
Middle Name:MOREEN
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6321 DANIELS PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4773
Mailing Address - Country:US
Mailing Address - Phone:941-626-1530
Mailing Address - Fax:
Practice Address - Street 1:13691 METRO PKWY STE 300
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4322
Practice Address - Country:US
Practice Address - Phone:239-264-1236
Practice Address - Fax:321-359-7055
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME102649208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000373700Medicaid
FL0172805OtherCIGNA
FLP00657339OtherRAILROAD MEDICARE
FL463262OtherWELLCARE
FL0172805OtherCIGNA