Provider Demographics
NPI:1346271418
Name:LEBER & BANDUCCI PLASTIC SURGERY LTD
Entity Type:Organization
Organization Name:LEBER & BANDUCCI PLASTIC SURGERY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:DEITER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:717-233-4691
Mailing Address - Street 1:2807 N FRONT ST
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17110-1222
Mailing Address - Country:US
Mailing Address - Phone:717-233-4691
Mailing Address - Fax:717-233-8836
Practice Address - Street 1:2807 N FRONT ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17110-1222
Practice Address - Country:US
Practice Address - Phone:717-233-4691
Practice Address - Fax:717-233-8836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-012624-E208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007401670002Medicaid
PA0007401670002Medicaid