Provider Demographics
NPI:1093850927
Name:LEAL, JORGE J (MD)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:J
Last Name:LEAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:825 N COURTENAY PKWY
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4652
Mailing Address - Country:US
Mailing Address - Phone:321-452-2563
Mailing Address - Fax:321-453-5841
Practice Address - Street 1:825 N COURTENAY PKWY
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4652
Practice Address - Country:US
Practice Address - Phone:321-452-2563
Practice Address - Fax:321-453-5841
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME29037208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL05400OtherBLUE CROSS BLUE SHIELD
1653673OtherCIGNA
406142183OtherRAIL ROAD MEDICARE
4104040OtherAETNA
4104040OtherAETNA
D61228Medicare UPIN