Provider Demographics
NPI:1164417473
Name:HUDDLESTON, LEON M (MD)
Entity Type:Individual
Prefix:DR
First Name:LEON
Middle Name:M
Last Name:HUDDLESTON
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:PO BOX 7227
Mailing Address - Street 2:
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-7227
Mailing Address - Country:US
Mailing Address - Phone:708-786-2900
Mailing Address - Fax:
Practice Address - Street 1:1401 S CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1858
Practice Address - Country:US
Practice Address - Phone:773-522-2010
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-113839-1Medicaid
ILI38785Medicare UPIN
ILK20117/209384Medicare ID - Type Unspecified