Provider Demographics
NPI:1508241076
Name:SOPHIA V. LEONIDA, MD PC
Entity Type:Organization
Organization Name:SOPHIA V. LEONIDA, MD PC
Other - Org Name:STATIONHOUSE PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MELITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-375-9350
Mailing Address - Street 1:2228 BLACK ROCK TPKE
Mailing Address - Street 2:SUITE 211
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-3237
Mailing Address - Country:US
Mailing Address - Phone:203-375-9350
Mailing Address - Fax:203-375-8013
Practice Address - Street 1:2228 BLACK ROCK TPKE
Practice Address - Street 2:SUITE 211
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-3237
Practice Address - Country:US
Practice Address - Phone:203-375-9350
Practice Address - Fax:203-375-8013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO070195363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004267383Medicaid
CTQ77898Medicare UPIN
CT004267383Medicaid