Provider Demographics
NPI:1689663619
Name:ROSARIO LEON, VIDAL (MD)
Entity Type:Individual
Prefix:
First Name:VIDAL
Middle Name:
Last Name:ROSARIO LEON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 372350
Mailing Address - Street 2:
Mailing Address - City:CAYEY
Mailing Address - State:PR
Mailing Address - Zip Code:00736
Mailing Address - Country:US
Mailing Address - Phone:787-738-8077
Mailing Address - Fax:888-483-2905
Practice Address - Street 1:108 CALLE JOSE C. VAZQUEZ
Practice Address - Street 2:
Practice Address - City:AIBONITO
Practice Address - State:PR
Practice Address - Zip Code:00705
Practice Address - Country:US
Practice Address - Phone:787-738-8077
Practice Address - Fax:888-483-2905
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-21
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PR0078152086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D08548Medicare UPIN