Provider Demographics
NPI:1669453528
Name:DE EVOLI, LELAND (DO)
Entity Type:Individual
Prefix:
First Name:LELAND
Middle Name:
Last Name:DE EVOLI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 SUMMIT CT
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FISHKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12524-1348
Mailing Address - Country:US
Mailing Address - Phone:845-897-0009
Mailing Address - Fax:845-897-0009
Practice Address - Street 1:2 SUMMIT CT
Practice Address - Street 2:SUITE 202
Practice Address - City:FISHKILL
Practice Address - State:NY
Practice Address - Zip Code:12524-1348
Practice Address - Country:US
Practice Address - Phone:845-897-0009
Practice Address - Fax:845-897-0009
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY125381-12084P0800X, 2084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00603163Medicaid
NY81M761Medicare ID - Type Unspecified
NY00603163Medicaid