Provider Demographics
NPI:1700820040
Name:GOSCINIAK, LEON EDMUND (DO)
Entity Type:Individual
Prefix:DR
First Name:LEON
Middle Name:EDMUND
Last Name:GOSCINIAK
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 1:705 STATE RD
Mailing Address - Street 2:
Mailing Address - City:CROYDON
Mailing Address - State:PA
Mailing Address - Zip Code:19021-7446
Mailing Address - Country:US
Mailing Address - Phone:215-785-3300
Mailing Address - Fax:215-785-0818
Practice Address - Street 1:705 STATE RD
Practice Address - Street 2:
Practice Address - City:CROYDON
Practice Address - State:PA
Practice Address - Zip Code:19021-7446
Practice Address - Country:US
Practice Address - Phone:215-785-3300
Practice Address - Fax:215-785-0818
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS004147L208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000675962Medicaid
PAB40500Medicare UPIN
PA165839Medicare ID - Type Unspecified