Provider Demographics
NPI:1639732381
Name:MONCADA MARTINEZ, LEONCIO EMILIO (SA-C)
Entity Type:Individual
Prefix:
First Name:LEONCIO
Middle Name:EMILIO
Last Name:MONCADA MARTINEZ
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8870 NW 103RD AVE
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-3290
Mailing Address - Country:US
Mailing Address - Phone:786-757-8828
Mailing Address - Fax:
Practice Address - Street 1:8870 NW 103RD AVE
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-3290
Practice Address - Country:US
Practice Address - Phone:786-757-8828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-18
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL14-154246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant