Provider Demographics
NPI:1952346017
Name:LEESBURG CARDIOVASCULAR ASSOCIATES LLC
Entity Type:Organization
Organization Name:LEESBURG CARDIOVASCULAR ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TREVA
Authorized Official - Middle Name:D
Authorized Official - Last Name:WIDDIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-787-9838
Mailing Address - Street 1:700 DOCTORS CT
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-7314
Mailing Address - Country:US
Mailing Address - Phone:352-787-9838
Mailing Address - Fax:352-787-8705
Practice Address - Street 1:700 DOCTORS CT
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-7314
Practice Address - Country:US
Practice Address - Phone:352-787-9838
Practice Address - Fax:352-787-8705
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORIDA HEART AND VASCULAR SURGEONS, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-20
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255785100Medicaid
FL21949OtherBCBS OF FLORIDA
FL21949Medicare PIN