Provider Demographics
NPI:1083664130
Name:SULIK, LEONARD READ (MD)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:READ
Last Name:SULIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12915 63RD AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-6001
Mailing Address - Country:US
Mailing Address - Phone:763-383-5800
Mailing Address - Fax:763-559-6450
Practice Address - Street 1:3415 SAINT PAUL AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-4342
Practice Address - Country:US
Practice Address - Phone:612-284-3220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN420892084P0800X, 2084P0804X
NDPT 121282084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN640727700Medicaid
MN640727700Medicaid
MN260003558Medicare PIN
H06540Medicare UPIN
MN260003557Medicare PIN