Provider Demographics
NPI:1750456406
Name:MARIE LAURA LEON M.D P.C
Entity Type:Organization
Organization Name:MARIE LAURA LEON M.D P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARLENA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPMSM
Authorized Official - Phone:646-680-2894
Mailing Address - Street 1:441 9TH AVE
Mailing Address - Street 2:ACP CREDENTIALING OFFICE - 3RD FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-1623
Mailing Address - Country:US
Mailing Address - Phone:646-680-2894
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:391 EASTERN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11216-4153
Practice Address - Country:US
Practice Address - Phone:718-613-1600
Practice Address - Fax:718-613-1666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1965772080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01682782Medicaid