Provider Demographics
NPI:1164617601
Name:CARLITO, LEONARDO (MPT)
Entity Type:Individual
Prefix:
First Name:LEONARDO
Middle Name:
Last Name:CARLITO
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 N SIERRA WAY
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-4817
Mailing Address - Country:US
Mailing Address - Phone:909-888-8152
Mailing Address - Fax:909-882-6110
Practice Address - Street 1:590 N SIERRA WAY
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-4817
Practice Address - Country:US
Practice Address - Phone:909-888-8152
Practice Address - Fax:909-882-6110
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-07
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1139400208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXOPT216720Medicare PIN