Provider Demographics
NPI:1598702276
Name:TACSA-CARRASCO, LEONCIO J (MD)
Entity Type:Individual
Prefix:DR
First Name:LEONCIO
Middle Name:J
Last Name:TACSA-CARRASCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:LEONCIO
Other - Middle Name:J
Other - Last Name:TACSA-CARRASCO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:585-922-1900
Mailing Address - Fax:
Practice Address - Street 1:1425 PORTLAND AVENUE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3001
Practice Address - Country:US
Practice Address - Phone:585-922-0567
Practice Address - Fax:585-922-2908
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME72300174400000X, 207R00000X, 208M00000X
NY186353208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No174400000XOther Service ProvidersSpecialist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5533503Medicaid
NJ5533503Medicaid
F64818Medicare UPIN