Provider Demographics
NPI:1285621318
Name:LEEDY, RICHARD F JR (DO)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:F
Last Name:LEEDY
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 STATE ROAD 415
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771
Mailing Address - Country:US
Mailing Address - Phone:407-367-0923
Mailing Address - Fax:407-322-5309
Practice Address - Street 1:5449 S SEMORAN BLVD
Practice Address - Street 2:SUITE 14
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-1722
Practice Address - Country:US
Practice Address - Phone:407-367-0923
Practice Address - Fax:407-322-5309
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS07678207Q00000X
OH340015002207QA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL220808OtherAMERIGROUP
FL254952200Medicaid
FL192902OtherWELLCARE
E2773Medicare ID - Type Unspecified
FL254952200Medicaid