Provider Demographics
NPI:1881689313
Name:LEON, WALFREDO J (MD)
Entity Type:Individual
Prefix:DR
First Name:WALFREDO
Middle Name:J
Last Name:LEON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2600 GREENBUSH ST
Mailing Address - Street 2:RCS PROVIDER ENROLLMENT
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2477
Mailing Address - Country:US
Mailing Address - Phone:765-448-8000
Mailing Address - Fax:765-448-8085
Practice Address - Street 1:450 CLARKSON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2056
Practice Address - Country:US
Practice Address - Phone:718-270-1821
Practice Address - Fax:718-270-1733
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2019-10-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301108970207R00000X, 207RC0200X
NY140366-1207RP1001X
IN01076586A207RC0200X
GA81216207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00764705Medicaid
NYB87519Medicare UPIN
NY00764705Medicaid