Provider Demographics
NPI:1487945333
Name:MEDARIS, LEIGH ANN (MD)
Entity type:Individual
Prefix:
First Name:LEIGH
Middle Name:ANN
Last Name:MEDARIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:487 30TH AVE N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33704-2118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10000 BAY PINES BLVD
Practice Address - Street 2:BUILDING 22, ROOM 355
Practice Address - City:BAY PINES
Practice Address - State:FL
Practice Address - Zip Code:33744
Practice Address - Country:US
Practice Address - Phone:727-398-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-27
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC172885207R00000X
NC2016-00280207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1487945333Medicaid
SCNC2868Medicaid
NCNCT632AMedicare PIN
NC1487945333Medicaid
NCNCT632BMedicare PIN