Provider Demographics
NPI:1407837701
Name:MOSCHOURIS, LEONIDAS P (MD)
Entity Type:Individual
Prefix:DR
First Name:LEONIDAS
Middle Name:P
Last Name:MOSCHOURIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LEONIDAS
Other - Middle Name:PETROS
Other - Last Name:MOSCHOURIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:15125 22 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-4406
Mailing Address - Country:US
Mailing Address - Phone:586-532-0599
Mailing Address - Fax:586-566-8967
Practice Address - Street 1:15125 22 MILE RD
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48315-4406
Practice Address - Country:US
Practice Address - Phone:586-532-0599
Practice Address - Fax:586-566-8967
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301078575208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
I22529Medicare UPIN
N54680003Medicare ID - Type Unspecified