Provider Demographics
NPI:1609063296
Name:LEILA PATALLO
Entity Type:Organization
Organization Name:LEILA PATALLO
Other - Org Name:TITUSVILLE NEUROLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:DELPHINE
Authorized Official - Middle Name:CELINE
Authorized Official - Last Name:JACQUET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-383-0900
Mailing Address - Street 1:1781 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-3221
Mailing Address - Country:US
Mailing Address - Phone:321-383-0900
Mailing Address - Fax:321-383-0024
Practice Address - Street 1:1781 GARDEN ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-3221
Practice Address - Country:US
Practice Address - Phone:321-383-0900
Practice Address - Fax:321-383-0024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-27
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME849822084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3956438OtherAETNA GROUP NUMBER
FLDD8925OtherPALMETTO GBA GROUP NUMBER
FL7735972OtherCIGNA
FL13868OtherBLUE CROSS BLUE SHIELD
FL7835391OtherAETNA
FL3956438OtherAETNA GROUP NUMBER
FLK8469Medicare PIN
FL13868YMedicare PIN