Provider Demographics
NPI:1831572254
Name:LEONOWICZ, NICHOLAS (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:LEONOWICZ
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10343 DAWSONS CREEK BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1906
Mailing Address - Country:US
Mailing Address - Phone:260-203-9600
Mailing Address - Fax:
Practice Address - Street 1:10343 DAWSONS CREEK BLVD STE A
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825
Practice Address - Country:US
Practice Address - Phone:260-206-9600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-02
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301108207207P00000X
IN01080188A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0378205Medicaid