Provider Demographics
NPI:1376533091
Name:PAGTAKHAN SO, LEONOR SALAMANCA (MD)
Entity Type:Individual
Prefix:
First Name:LEONOR
Middle Name:SALAMANCA
Last Name:PAGTAKHAN SO
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:PO BOX 2708
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-2708
Mailing Address - Country:US
Mailing Address - Phone:606-432-0174
Mailing Address - Fax:606-437-0438
Practice Address - Street 1:156 ISLAND CREEK RD
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-9340
Practice Address - Country:US
Practice Address - Phone:606-432-0174
Practice Address - Fax:606-437-0438
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17816207K00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64178163Medicaid
KY289101Medicare PIN
D32293Medicare UPIN