Provider Demographics
NPI:1336182237
Name:LEO, GARY J (DO)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:J
Last Name:LEO
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:4425 N PORT WASHINGTON RD
Mailing Address - Street 2:CSMCP CLINIC CREDENTIALING
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1082
Mailing Address - Country:US
Mailing Address - Phone:414-319-3000
Mailing Address - Fax:414-319-3033
Practice Address - Street 1:2311 N PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4445
Practice Address - Country:US
Practice Address - Phone:414-319-3000
Practice Address - Fax:414-319-3033
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2013-02-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI238072084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology