Provider Demographics
NPI:1689052664
Name:BRASILIENSE, LEONARDO B C (MD)
Entity Type:Individual
Prefix:DR
First Name:LEONARDO
Middle Name:B C
Last Name:BRASILIENSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 190930
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83719-0930
Mailing Address - Country:US
Mailing Address - Phone:208-236-7051
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:1072 N LIBERTY ST STE 200
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8963
Practice Address - Country:US
Practice Address - Phone:208-302-4100
Practice Address - Fax:208-302-4135
Is Sole Proprietor?:No
Enumeration Date:2015-05-11
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61270647207T00000X
IDM-17423207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2213825Medicaid