Provider Demographics
NPI:1952315491
Name:CARTER, LEO RONDUS (MD)
Entity Type:Individual
Prefix:DR
First Name:LEO
Middle Name:RONDUS
Last Name:CARTER
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 1:2115 EXECUTIVE DR STE 2D
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-2411
Mailing Address - Country:US
Mailing Address - Phone:757-827-1351
Mailing Address - Fax:
Practice Address - Street 1:2115 EXECUTIVE DR STE 2D
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2411
Practice Address - Country:US
Practice Address - Phone:757-827-1351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101029490174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA51268OtherOPTIMA HEALTH
VA6500196Medicaid
VA220094OtherMAMSI
VA51268OtherOPTIMA HEALTH