Provider Demographics
NPI:1275548711
Name:DECASTRO, LEONORA BONLEON (MD)
Entity Type:Individual
Prefix:DR
First Name:LEONORA
Middle Name:BONLEON
Last Name:DECASTRO
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 1:6 SKINNER ST
Mailing Address - Street 2:
Mailing Address - City:PORT JERVIS
Mailing Address - State:NY
Mailing Address - Zip Code:12771-2225
Mailing Address - Country:US
Mailing Address - Phone:845-856-7529
Mailing Address - Fax:845-856-5656
Practice Address - Street 1:6 SKINNER ST
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771-2225
Practice Address - Country:US
Practice Address - Phone:845-856-7529
Practice Address - Fax:845-856-5656
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00662859Medicaid
NY00662859Medicaid
NY00662859Medicaid