Provider Demographics
NPI:1245211895
Name:LEONARD, ELLEN IMBER (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:IMBER
Last Name:LEONARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 ROCKHILL DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-2220
Mailing Address - Country:US
Mailing Address - Phone:210-862-7963
Mailing Address - Fax:
Practice Address - Street 1:6711 S NEW BRAUNFELS AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78223-3005
Practice Address - Country:US
Practice Address - Phone:210-862-7963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH05582081P0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPediatric Rehabilitation Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH0558OtherSTATE MEDICAL LICENSE
TX1295800-02Medicaid
TXE52113Medicare UPIN
TX88Y059Medicare ID - Type Unspecified