Provider Demographics
NPI:1205871779
Name:LEVEILLE, LEONARD (MD)
Entity type:Individual
Prefix:
First Name:LEONARD
Middle Name:
Last Name:LEVEILLE
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:PO BOX 8003
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54912-8003
Mailing Address - Country:US
Mailing Address - Phone:920-996-3298
Mailing Address - Fax:920-738-5787
Practice Address - Street 1:4480 W SPENCER ST
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914-9106
Practice Address - Country:US
Practice Address - Phone:920-738-4800
Practice Address - Fax:920-738-5749
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI37221207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI001345003OtherMEDICARE PTAN
WI32174700Medicaid
WI32174700Medicaid