Provider Demographics
NPI:1578648606
Name:MCLEOD-LABISSIERE, RENIKA N (MD)
Entity Type:Individual
Prefix:
First Name:RENIKA
Middle Name:N
Last Name:MCLEOD-LABISSIERE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 W REDDING RD
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-8345
Mailing Address - Country:US
Mailing Address - Phone:203-743-1810
Mailing Address - Fax:
Practice Address - Street 1:115 WATERBURY ROAD
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:CT
Practice Address - Zip Code:06712
Practice Address - Country:US
Practice Address - Phone:203-758-5660
Practice Address - Fax:203-758-3161
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230651207Q00000X
CT045025207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
103932Medicare UPIN