Provider Demographics
NPI:1629197876
Name:LEONARD, MICHAEL F (LIC AC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:F
Last Name:LEONARD
Suffix:
Gender:M
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 PARKWAY RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-1021
Mailing Address - Country:US
Mailing Address - Phone:781-376-9292
Mailing Address - Fax:
Practice Address - Street 1:OMTA
Practice Address - Street 2:400 WEST CUMMINGS PARK - SUITE 500
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801
Practice Address - Country:US
Practice Address - Phone:781-376-9292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA219562171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist