Provider Demographics
NPI:1235393760
Name:LEONTIEV, OLEG (MD)
Entity Type:Individual
Prefix:
First Name:OLEG
Middle Name:
Last Name:LEONTIEV
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 1:51 N 39TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-2640
Mailing Address - Country:US
Mailing Address - Phone:215-349-5454
Mailing Address - Fax:
Practice Address - Street 1:51 N 39TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-2640
Practice Address - Country:US
Practice Address - Phone:215-349-5454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-14
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4432662085R0202X
PAMT1935482085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1028640680001Medicaid
PA308716Medicare PIN