Provider Demographics
NPI:1760576599
Name:KIRCIK, LEON H (MD)
Entity Type:Individual
Prefix:
First Name:LEON
Middle Name:H
Last Name:KIRCIK
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 1:1169 EASTERN PKWY 2310
Mailing Address - Street 2:
Mailing Address - City:LOUSIVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217
Mailing Address - Country:US
Mailing Address - Phone:502-451-9000
Mailing Address - Fax:502-456-2728
Practice Address - Street 1:1169 EASTERN PKWY 2310
Practice Address - Street 2:
Practice Address - City:LOUSIVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217
Practice Address - Country:US
Practice Address - Phone:502-456-2783
Practice Address - Fax:502-456-2728
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31894207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64318942Medicaid
0698501Medicare PIN
F50540Medicare UPIN