Provider Demographics
NPI:1417994120
Name:BALACCO, LEONARD MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:MICHAEL
Last Name:BALACCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-4659
Mailing Address - Country:US
Mailing Address - Phone:201-656-5688
Mailing Address - Fax:201-656-8975
Practice Address - Street 1:108 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-4659
Practice Address - Country:US
Practice Address - Phone:201-656-5688
Practice Address - Fax:201-656-8975
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA41027207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1469207Medicaid
NJC60230Medicare UPIN
NJ196091BY2Medicare ID - Type Unspecified