Provider Demographics
NPI:1851332944
Name:MOYSAENKO, LEO (MD)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:
Last Name:MOYSAENKO
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 1:4410 W RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:OH
Mailing Address - Zip Code:44134-4122
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:33001 SOLON RD
Practice Address - Street 2:
Practice Address - City:SOLON
Practice Address - State:OH
Practice Address - Zip Code:44139-2839
Practice Address - Country:US
Practice Address - Phone:440-349-2516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35052898207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0708032Medicaid
OHP00222425OtherMEDICARE RR-GA
OH942460636142OtherCARESOURCE
OHMO4158251Medicare ID - Type Unspecified
OHA17533Medicare UPIN