Provider Demographics
NPI:1477789964
Name:LETONOFF ORTHOPAEDICS & SPORTS
Entity Type:Organization
Organization Name:LETONOFF ORTHOPAEDICS & SPORTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIG
Authorized Official - Middle Name:J
Authorized Official - Last Name:LETONOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:228-896-4747
Mailing Address - Street 1:452 COURT HOUSE ROAD
Mailing Address - Street 2:SUITE G
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507
Mailing Address - Country:US
Mailing Address - Phone:228-896-4747
Mailing Address - Fax:228-896-4740
Practice Address - Street 1:452 COURT HOUSE ROAD
Practice Address - Street 2:SUITE G
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39507
Practice Address - Country:US
Practice Address - Phone:228-896-4747
Practice Address - Fax:228-896-4740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-10
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18468207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS302I209846Medicare PIN