Provider Demographics
NPI:1255933115
Name:LEODEZ
Entity type:Organization
Organization Name:LEODEZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BYRON
Authorized Official - Middle Name:OSWALDO
Authorized Official - Last Name:MATA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:786-427-4450
Mailing Address - Street 1:3899 GRASSLAND LOOP
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-4120
Mailing Address - Country:US
Mailing Address - Phone:407-394-2645
Mailing Address - Fax:
Practice Address - Street 1:4292 CHAMBLEE TUCKER RD
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-2103
Practice Address - Country:US
Practice Address - Phone:770-718-1517
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:B MATA LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-11-14
Last Update Date:2020-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty