Provider Demographics
NPI:1609815216
Name:SULAS, LEONAS PRANAS (MD)
Entity Type:Individual
Prefix:
First Name:LEONAS
Middle Name:PRANAS
Last Name:SULAS
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 1:2817 NEW PINERY ROAD, PO BOX 387
Mailing Address - Street 2:DIVINE SAVIOR HEALTHCARE
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-0387
Mailing Address - Country:US
Mailing Address - Phone:608-745-5603
Mailing Address - Fax:608-742-6098
Practice Address - Street 1:2817 NEW PINERY ROAD
Practice Address - Street 2:DIVINE SAVIOR HEALTHCARE
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-0387
Practice Address - Country:US
Practice Address - Phone:608-745-5603
Practice Address - Fax:608-742-6098
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI27361020208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI60643OtherDEAN HEALTH INSURANCE
WI30689000Medicaid
WI60643OtherDEAN HEALTH INSURANCE