Provider Demographics
NPI:1275520470
Name:DERIGGI, LEONARD A (MD)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:A
Last Name:DERIGGI
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 1:3572 BRODHEAD RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MONACA
Mailing Address - State:PA
Mailing Address - Zip Code:15061-3101
Mailing Address - Country:US
Mailing Address - Phone:724-728-6539
Mailing Address - Fax:724-728-7416
Practice Address - Street 1:1000 DUTCH RIDGE RD
Practice Address - Street 2:DEPARTMENT OF RADIOLOGY
Practice Address - City:BEAVER
Practice Address - State:PA
Practice Address - Zip Code:15009-9727
Practice Address - Country:US
Practice Address - Phone:724-773-4567
Practice Address - Fax:724-728-9729
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD051921L2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015378800025Medicaid
WV3810006135Medicaid
PA0815059000OtherINDEPENDENCE BLUE CROSS
PADE789597OtherHIGHMARK
PA0015378800007Medicaid
G10831Medicare UPIN
789597Medicare ID - Type Unspecified
PA300080347Medicare PIN