Provider Demographics
NPI:1366519266
Name:LEONG, KENNETH (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:LEONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2911 48TH ST W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-6131
Mailing Address - Country:US
Mailing Address - Phone:818-454-6359
Mailing Address - Fax:
Practice Address - Street 1:1921 WALDEMERE ST STE 504
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239
Practice Address - Country:US
Practice Address - Phone:941-952-4001
Practice Address - Fax:941-952-4028
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG81070208200000X
FLME1280872082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G22163Medicare UPIN
CA00G810700Medicaid