Provider Demographics
NPI:1710098652
Name:LEONARD, WILBERT M (DPM)
Entity Type:Individual
Prefix:DR
First Name:WILBERT
Middle Name:M
Last Name:LEONARD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:MARC
Other - Middle Name:
Other - Last Name:LEONARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2708 MCGRAW DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-6012
Mailing Address - Country:US
Mailing Address - Phone:309-663-2306
Mailing Address - Fax:309-662-1213
Practice Address - Street 1:2708 MCGRAW DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-6012
Practice Address - Country:US
Practice Address - Phone:309-663-2306
Practice Address - Fax:309-662-1213
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016004981213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004981Medicaid
L87984Medicare PIN
IL016004981Medicaid