Provider Demographics
NPI:1518245547
Name:BASS, LEONARD CHANNING (MD)
Entity Type:Individual
Prefix:
First Name:LEONARD
Middle Name:CHANNING
Last Name:BASS
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 1:398 CAMINO GARDENS BLVD
Mailing Address - Street 2:102
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-5827
Mailing Address - Country:US
Mailing Address - Phone:561-929-9104
Mailing Address - Fax:561-392-3793
Practice Address - Street 1:398 CAMINO GARDENS BLVD
Practice Address - Street 2:102
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-5827
Practice Address - Country:US
Practice Address - Phone:561-929-9104
Practice Address - Fax:561-392-3793
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-25
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME14256208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice