Provider Demographics
NPI:1346275948
Name:PATALLO, LEILA M (MD)
Entity Type:Individual
Prefix:DR
First Name:LEILA
Middle Name:M
Last Name:PATALLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1350 HICKORY ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901
Practice Address - Country:US
Practice Address - Phone:321-434-1771
Practice Address - Fax:321-434-1775
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME849822084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL134295171OtherTRICARE SOUTH GROUP #
FLDD8925OtherPALMETTO GBA GROUP #
FLP01361854OtherHF RR MEDICARE
FL014628100Medicaid
FL3956438OtherAETNA GROUP NUMBER
FL134295178OtherFIRST HEALTH
FL7835391OtherAETNA PROVIDER NUMBER
FL134295178OtherHEALTH FIRST
FL13868OtherBLUE CROSS BLUE SHIELD
FL3098980OtherGHI
FL7735972OtherCIGNA
FL134295178OtherUNITED HEALTHCARE
FLDD8925OtherPALMETTO GBA GROUP #