Provider Demographics
NPI:1811036130
Name:DICK, LEON SHERMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:LEON
Middle Name:SHERMAN
Last Name:DICK
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 1:2232 MILLBURN AVE
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-2605
Mailing Address - Country:US
Mailing Address - Phone:973-763-8087
Mailing Address - Fax:973-763-6482
Practice Address - Street 1:2232 MILLBURN AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-2605
Practice Address - Country:US
Practice Address - Phone:973-763-8087
Practice Address - Fax:973-763-6482
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03208100174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MA03208100OtherNJ LICENSE
NJC54249Medicare UPIN
NJ428702Medicare ID - Type Unspecified