Provider Demographics
NPI: | 1700847464 |
---|---|
Name: | FORERO, LEONARDO (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | LEONARDO |
Middle Name: | |
Last Name: | FORERO |
Suffix: | |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | PO BOX 911230 |
Mailing Address - Street 2: | |
Mailing Address - City: | DALLAS |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 75391-1230 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 972-997-8000 |
Mailing Address - Fax: | 972-437-9605 |
Practice Address - Street 1: | 1000 S COULTER ST |
Practice Address - Street 2: | SUITE 100 |
Practice Address - City: | AMARILLO |
Practice Address - State: | TX |
Practice Address - Zip Code: | 79106-1781 |
Practice Address - Country: | US |
Practice Address - Phone: | 806-358-8654 |
Practice Address - Fax: | 806-356-8687 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-03-31 |
Last Update Date: | 2021-12-20 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | M0076 | 207RH0003X, 207RX0202X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RX0202X | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
No | 207RH0003X | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 174488002 | Medicaid | |
TX | P00289946 | Medicare PIN | |
TX | 8G4014 | Medicare PIN |