Provider Demographics
NPI:1972842680
Name:MOURAO, LEONARDO D (IDC)
Entity Type:Individual
Prefix:
First Name:LEONARDO
Middle Name:D
Last Name:MOURAO
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1ST MLG 7TH ESB
Mailing Address - Street 2:555677
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:92055-0000
Mailing Address - Country:US
Mailing Address - Phone:760-725-5865
Mailing Address - Fax:
Practice Address - Street 1:618 PUSAN DR
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058-8148
Practice Address - Country:US
Practice Address - Phone:760-725-5865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-01
Last Update Date:2013-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA$$$$$$$$$OtherTRICARE