Provider Demographics
NPI:1124039813
Name:HORMAZA, LEONARDO RAFAEL (MD)
Entity Type:Individual
Prefix:
First Name:LEONARDO
Middle Name:RAFAEL
Last Name:HORMAZA
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 1:274 DORADO BCH E
Mailing Address - Street 2:
Mailing Address - City:DORADO
Mailing Address - State:PR
Mailing Address - Zip Code:00646-2213
Mailing Address - Country:US
Mailing Address - Phone:787-727-1000
Mailing Address - Fax:
Practice Address - Street 1:253 CALLE SAN JORGE
Practice Address - Street 2:SUIE 2B
Practice Address - City:SANTURCE
Practice Address - State:PR
Practice Address - Zip Code:00912-3307
Practice Address - Country:US
Practice Address - Phone:787-999-9450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-115444208000000X
PR153462080P0206X, 2080T0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080T0004XAllopathic & Osteopathic PhysiciansPediatricsPediatric Transplant Hepatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1055271Medicaid