Provider Demographics
NPI:1184677403
Name:ALTAMIRANO, LEO (MD)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:
Last Name:ALTAMIRANO
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 1:311 E SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67846
Mailing Address - Country:US
Mailing Address - Phone:620-275-3700
Mailing Address - Fax:
Practice Address - Street 1:311 E SPRUCE ST
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:KS
Practice Address - Zip Code:67846
Practice Address - Country:US
Practice Address - Phone:620-275-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-34459208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200657740AMedicaid
KS04-34459OtherKS LICENSE
KS200657740AMedicaid