Provider Demographics
NPI:1003084138
Name:LEO, ANGELA MARIE (DO)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:LEO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:ANGELA
Other - Middle Name:MARIE
Other - Last Name:LEO-NIEBERG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:1717 86TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-2817
Mailing Address - Country:US
Mailing Address - Phone:718-331-3122
Mailing Address - Fax:
Practice Address - Street 1:1717 86TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-2817
Practice Address - Country:US
Practice Address - Phone:718-331-3122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-11
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT011311207N00000X
NY251544-1207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology