Provider Demographics
NPI:1336145085
Name:SIDOREK, LEON C (DPM)
Entity Type:Individual
Prefix:DR
First Name:LEON
Middle Name:C
Last Name:SIDOREK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 GRACE DR
Mailing Address - Street 2:STE 2
Mailing Address - City:TUNKHANNOCK
Mailing Address - State:PA
Mailing Address - Zip Code:18657-9120
Mailing Address - Country:US
Mailing Address - Phone:570-836-3668
Mailing Address - Fax:570-836-5710
Practice Address - Street 1:12 GRACE DR
Practice Address - Street 2:SUITE 2
Practice Address - City:TUNKHANNOCK
Practice Address - State:PA
Practice Address - Zip Code:18657-9120
Practice Address - Country:US
Practice Address - Phone:570-836-3668
Practice Address - Fax:570-836-5710
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC-002903-L213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010088450003Medicaid
PAT-29266Medicare UPIN
PA121838Medicare PIN
PA4683950001Medicare NSC