Basic Information
| Provider Information | |||||||||
| NPI: | 1720203854 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEROUX | ||||||||
| FirstName: | PIERRE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1223 GATEWAY DR | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329012607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217254500 | ||||||||
| FaxNumber: | 3219517408 | ||||||||
| Practice Location | |||||||||
| Address1: | 8745 N WICKHAM RD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329405997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214349483 | ||||||||
| FaxNumber: | 3214349482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2007 | ||||||||
| LastUpdateDate: | 08/05/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME100694 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 208M00000X | ME100694 | FL | Y | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | 063486 | GA | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000327400 | 05 | FL | MEDICAID | 68136 | 01 | FL | BCBS | OTHER |