Provider Demographics
NPI:1487259693
Name:JIMENEZ-CORDERO, LEISA
Entity type:Individual
Prefix:
First Name:LEISA
Middle Name:
Last Name:JIMENEZ-CORDERO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 W COLONIAL DR STE 303
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-6863
Mailing Address - Country:US
Mailing Address - Phone:787-636-9110
Mailing Address - Fax:689-304-0303
Practice Address - Street 1:851 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-2085
Practice Address - Country:US
Practice Address - Phone:407-332-0003
Practice Address - Fax:321-295-7928
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-03
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR24206208D00000X
FLACN1713208D00000X, 208D00000X
FL98363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLACN1713OtherFL MEDICAL LICENSE
FL126583800Medicaid