Provider Demographics
NPI:1477645745
Name:LEONAS, THEODORE STANLEY JR (DPM)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:STANLEY
Last Name:LEONAS
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1365 BENTON ST
Mailing Address - Street 2:
Mailing Address - City:CRETE
Mailing Address - State:IL
Mailing Address - Zip Code:60417-2850
Mailing Address - Country:US
Mailing Address - Phone:708-672-4414
Mailing Address - Fax:708-672-4424
Practice Address - Street 1:1365 BENTON ST
Practice Address - Street 2:
Practice Address - City:CRETE
Practice Address - State:IL
Practice Address - Zip Code:60417-2850
Practice Address - Country:US
Practice Address - Phone:708-672-4414
Practice Address - Fax:708-672-4424
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL16-003153213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214179Medicare PIN