Provider Demographics
NPI:1699188656
Name:LEOTAUD-MORENO, JANE GM (MD)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:GM
Last Name:LEOTAUD-MORENO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:GM
Other - Last Name:LEOTAUD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:785 5TH AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-4232
Mailing Address - Country:US
Mailing Address - Phone:717-263-9555
Mailing Address - Fax:717-709-6529
Practice Address - Street 1:601 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:PA
Practice Address - Zip Code:17268-2332
Practice Address - Country:US
Practice Address - Phone:717-765-5085
Practice Address - Fax:717-765-5066
Is Sole Proprietor?:No
Enumeration Date:2014-06-07
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD452196207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP01361232OtherRRMC
PA102926634Medicaid
PAP01361232OtherRRMC
PA360601LN7Medicare PIN