Provider Demographics
NPI:1497971212
Name:PAJARILLO, LEO PANTILLA (MD)
Entity Type:Individual
Prefix:DR
First Name:LEO
Middle Name:PANTILLA
Last Name:PAJARILLO
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:PO BOX 2080
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661-2080
Mailing Address - Country:US
Mailing Address - Phone:304-236-5902
Mailing Address - Fax:304-235-4049
Practice Address - Street 1:186 E 2ND AVE STE 100
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3602
Practice Address - Country:US
Practice Address - Phone:304-236-5902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV11772208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64698426Medicaid
WV0112030000Medicaid
D49105Medicare UPIN