Provider Demographics
NPI:1295065399
Name:LEANO, PAUL MARAVILLA (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:MARAVILLA
Last Name:LEANO
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 1:1008 MORGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHATTAHOOCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:32324-1915
Mailing Address - Country:US
Mailing Address - Phone:850-663-8150
Mailing Address - Fax:
Practice Address - Street 1:1008 MORGAN AVE
Practice Address - Street 2:
Practice Address - City:CHATTAHOOCHEE
Practice Address - State:FL
Practice Address - Zip Code:32324-1915
Practice Address - Country:US
Practice Address - Phone:850-663-8150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-12
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 281002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2267Medicare PIN
FLF11082Medicare UPIN