| Entity Name: | MARK LEEDS, D.O., P.A. |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 06 Oct 2005 (19 years ago) |
| Document Number: | P05000137215 |
| FEI/EIN Number | 204103033 |
| Address: | 3290 NE 33RD ST, FORT LAUDERDALE, FL, 33308, US |
| Mail Address: | 3290 NE 33RD ST, FORT LAUDERDALE, FL, 33308, US |
| ZIP code: | 33308 |
| County: | Broward |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1538174941 | 2006-07-31 | 2014-08-08 | 304 INDIAN TRACE #528, WESTON, FL, 33326, US | 304 INDIAN TRACE #528, WESTON, FL, 33326, US | |||||||||||||||||||||||||
|
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| Phone | +1 954-776-6226 |
| Fax | 9546928120 |
Authorized person
| Name | DR. MARK JEFFREY LEEDS |
| Role | PRESIDENT |
| Phone | 9547766226 |
Taxonomy
| Taxonomy Code | 207Q00000X - Family Medicine Physician |
| License Number | OS7559 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 274554200 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| LEEDS MARK | Agent | 3290 NE 33RD ST, FORT LAUDERDALE, FL, 33308 |
| Name | Role | Address |
|---|---|---|
| LEEDS MARK JDr. | President | 3290 NE 33RD ST, FORT LAUDERDALE, FL, 33308 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2024-02-03 | 3290 NE 33RD ST, FORT LAUDERDALE, FL 33308 | No data |
| CHANGE OF MAILING ADDRESS | 2024-02-03 | 3290 NE 33RD ST, FORT LAUDERDALE, FL 33308 | No data |
| REGISTERED AGENT NAME CHANGED | 2024-02-03 | LEEDS, MARK | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2024-02-03 | 3290 NE 33RD ST, FORT LAUDERDALE, FL 33308 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-02-03 |
| ANNUAL REPORT | 2023-01-26 |
| ANNUAL REPORT | 2022-01-26 |
| ANNUAL REPORT | 2021-01-12 |
| ANNUAL REPORT | 2020-01-30 |
| ANNUAL REPORT | 2019-02-11 |
| ANNUAL REPORT | 2018-01-30 |
| ANNUAL REPORT | 2017-01-23 |
| ANNUAL REPORT | 2016-01-19 |
| ANNUAL REPORT | 2015-01-22 |
Date of last update: 02 Feb 2025
Sources: Florida Department of State
