Provider Demographics
NPI:1184619371
Name:LEO, PHILIP (MD)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:LEO
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 1:11 RALPH PL
Mailing Address - Street 2:SUITE 213
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-4419
Mailing Address - Country:US
Mailing Address - Phone:718-556-9400
Mailing Address - Fax:
Practice Address - Street 1:11 RALPH PL
Practice Address - Street 2:SUITE 213
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-4419
Practice Address - Country:US
Practice Address - Phone:718-556-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2012-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY146569207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY59A141Medicare ID - Type Unspecified
NYC11485Medicare UPIN