Provider Demographics
NPI:1861275984
Name:DIEZ PEREZ, LEONARDO ENRIQUE
Entity type:Individual
Prefix:
First Name:LEONARDO
Middle Name:ENRIQUE
Last Name:DIEZ PEREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3544 SAINT JOHNS BLUFF RD S APT 322
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-2666
Mailing Address - Country:US
Mailing Address - Phone:786-580-8358
Mailing Address - Fax:
Practice Address - Street 1:858 MONUMENT RD # P
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-6670
Practice Address - Country:US
Practice Address - Phone:904-450-8060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11027991363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily