Provider Demographics
NPI:1962401067
Name:LEITNER, MARK G (DPM)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:G
Last Name:LEITNER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 BUCKINGHAM PL
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4910
Mailing Address - Country:US
Mailing Address - Phone:813-571-2977
Mailing Address - Fax:813-654-9545
Practice Address - Street 1:206 BUCKINGHAM PL
Practice Address - Street 2:SUITE 101
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4910
Practice Address - Country:US
Practice Address - Phone:813-571-2977
Practice Address - Fax:813-654-9545
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2569213E00000X, 213ES0103X, 213ES0131X, 213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00415451OtherRAILROAD MEDICARE
FL202703OtherAMERIGROUP
FL10172301OtherCITRUS
FL864973OtherUHC
FL76166OtherBEECHSTREET
PO2569OtherLICENSE NO
FL1006007OtherHEALTHNET/CAREPLUS
FL390319200Medicaid
FL4961325OtherCIGNA
FL65462OtherBCBS
PO2569OtherLICENSE NO
FL65462OtherBCBS
FLU01289Medicare UPIN