Provider Demographics
NPI:1619040607
Name:DUNNDER LEACOCK, GLORIA (MD)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:DUNNDER LEACOCK
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 1:440 E 20TH ST
Mailing Address - Street 2:APT 9B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10009-8213
Mailing Address - Country:US
Mailing Address - Phone:212-545-2400
Mailing Address - Fax:646-312-0481
Practice Address - Street 1:3096 51ST ST
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-1457
Practice Address - Country:US
Practice Address - Phone:718-204-1469
Practice Address - Fax:718-545-1726
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY204175207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00695941Medicaid
NYG100000410Medicare Oscar/Certification
NY331009Medicare Oscar/Certification
NY331978Medicare PIN
NY00695941Medicaid