Provider Demographics
NPI:1114460474
Name:DE LEON, MICHAEL ANGELO
Entity Type:Individual
Prefix:
First Name:MICHAEL ANGELO
Middle Name:
Last Name:DE LEON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7345 WOODLAND DRIVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278
Mailing Address - Country:US
Mailing Address - Phone:317-286-2885
Mailing Address - Fax:317-536-3097
Practice Address - Street 1:7345 WOODLAND DRIVE
Practice Address - Street 2:SUITE C
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278
Practice Address - Country:US
Practice Address - Phone:317-286-2885
Practice Address - Fax:317-536-3097
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-18
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040242225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist