Provider Demographics
NPI:1437198348
Name:BUCCELLATO, LEONARD (MD)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:
Last Name:BUCCELLATO
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 1:1040 SIERRA DR STE 400
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-7241
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:
Practice Address - Street 1:761 45TH ST
Practice Address - Street 2:STE 108
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2893
Practice Address - Country:US
Practice Address - Phone:219-922-5416
Practice Address - Fax:219-922-3745
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058760207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM471400308OtherMEDICARE PTAN
IN200493840Medicaid
IN499500 JJJMedicare PIN
INM471400308OtherMEDICARE PTAN