Provider Demographics
NPI:1174781769
Name:MARK G LEITNER DPM PA
Entity type:Organization
Organization Name:MARK G LEITNER DPM PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:LEITNER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:813-571-2977
Mailing Address - Street 1:206 BUCKINGHAM PL
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4910
Mailing Address - Country:US
Mailing Address - Phone:813-657-9669
Mailing Address - Fax:813-654-9545
Practice Address - Street 1:15511 N FLORIDA AVE
Practice Address - Street 2:SUITE B2
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-1263
Practice Address - Country:US
Practice Address - Phone:813-963-3124
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2569213E00000X, 213EP1101X, 213ES0103X, 213ES0131X
FLPO3199213EP1101X, 213ES0103X, 213ES0131X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPO3199OtherMEDICAL LICENSE - JOHNSON
FL340534600Medicaid
FL65891OtherBCBS - JOHNSON
FL390319200Medicaid
FL65462OtherBCBS - LEITNER
FLDG1014OtherRAILROAD MEDICARE
FLPO2569OtherMEDICAL LICENSE - LEITNER
FL4724890001Medicare NSC
FLAC289Medicare PIN
FL65891OtherBCBS - JOHNSON
FLPO2569OtherMEDICAL LICENSE - LEITNER
FLU01289Medicare UPIN