Provider Demographics
NPI:1366600959
Name:MARK G LEITNER DPM
Entity type:Organization
Organization Name:MARK G LEITNER DPM
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 1:3638 LITHIA PINECREST RD
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33596-6305
Mailing Address - Country:US
Mailing Address - Phone:813-657-9669
Mailing Address - Fax:
Practice Address - Street 1:132 S MOON AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5110
Practice Address - Country:US
Practice Address - Phone:813-571-2977
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3189213E00000X
FLPO2569213EP1101X, 213ES0103X, 213ES0131X, 213E00000X
FLPO3199213EP1101X, 213ES0103X, 213ES0131X
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
FL340534600Medicaid
FLPO3199OtherMEDICAL LICENSE - JOHNSON
FL65462OtherBCBS - LEITNER
FLDG1014OtherRAILROAD MEDICARE
FL65891OtherBCBS - JOHNSON
FL390319200Medicaid
FLPO2569OtherMEDICAL LICENSE - LEITNER
FLPO2569OtherMEDICAL LICENSE - LEITNER
FL65891OtherBCBS - JOHNSON
FLPO3199OtherMEDICAL LICENSE - JOHNSON
FL340534600Medicaid
FL5547390001Medicare NSC