Provider Demographics
NPI:1740271642
Name:MANDESE, LEANN J (OD)
Entity type:Individual
Prefix:DR
First Name:LEANN
Middle Name:J
Last Name:MANDESE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2194 HIGHWAY A1A STE 109-110
Mailing Address - Street 2:
Mailing Address - City:INDIAN HARBOUR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-4930
Mailing Address - Country:US
Mailing Address - Phone:321-777-1670
Mailing Address - Fax:321-773-0187
Practice Address - Street 1:2194 A1A HWY
Practice Address - Street 2:SUITE 109
Practice Address - City:INDIAN HARBOUR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-4930
Practice Address - Country:US
Practice Address - Phone:321-777-1670
Practice Address - Fax:321-773-0187
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP3125152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1548473887OtherORGANIZATION
U73082Medicare UPIN
E1667Medicare ID - Type Unspecified