Provider Demographics
NPI:1578523668
Name:CLAVECILLA, LEO (MD)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:
Last Name:CLAVECILLA
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 1:525 E MARKET ST
Mailing Address - Street 2:PO BOX 2090
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44304-1619
Mailing Address - Country:US
Mailing Address - Phone:330-996-0347
Mailing Address - Fax:330-996-0359
Practice Address - Street 1:2040 E MARKET ST
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44312-1100
Practice Address - Country:US
Practice Address - Phone:330-784-2224
Practice Address - Fax:330-784-4021
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-068869C207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH729745OtherBUCKEYE COMMUNITY HEALTH
OH0416428Medicaid
OH480OtherSUMMACARE
OH0805314OtherMEDICARE ID
OHG29293Medicare UPIN