Provider Demographics
NPI:1811992175
Name:LEONARD R CACIOPPO MD PA
Entity type:Organization
Organization Name:LEONARD R CACIOPPO MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:R
Authorized Official - Last Name:CACIOPPO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-596-4030
Mailing Address - Street 1:14543 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-6065
Mailing Address - Country:US
Mailing Address - Phone:352-596-4030
Mailing Address - Fax:352-596-1997
Practice Address - Street 1:14543 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-6065
Practice Address - Country:US
Practice Address - Phone:352-596-4030
Practice Address - Fax:352-596-1997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-14
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0400447OtherGHI
FL72166OtherHORIZON
FLCM8147OtherRAILROAD MEDICARE
FL72166OtherBLUE CROSS BLUE SHIELD
FL5670278OtherAETNA
FL0587570001Medicare NSC
FLCM8147OtherRAILROAD MEDICARE