Provider Demographics
NPI:1265485189
Name:GO, LEONARDO (MD)
Entity type:Individual
Prefix:
First Name:LEONARDO
Middle Name:
Last Name:GO
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 1:3944 MILLER
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025
Mailing Address - Country:US
Mailing Address - Phone:773-721-7050
Mailing Address - Fax:773-721-7050
Practice Address - Street 1:2615 E 75TH STREET
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649
Practice Address - Country:US
Practice Address - Phone:773-721-7050
Practice Address - Fax:773-721-7050
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207R00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D15579Medicare UPIN
731710Medicare ID - Type Unspecified