Provider Demographics
NPI:1841261641
Name:LECUONA, MARIO (MD)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:
Last Name:LECUONA
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 1:230 STEUBEN ST
Mailing Address - Street 2:
Mailing Address - City:MONTOUR FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:14865-9648
Mailing Address - Country:US
Mailing Address - Phone:607-210-1968
Mailing Address - Fax:607-210-1971
Practice Address - Street 1:230 STEUBEN ST
Practice Address - Street 2:
Practice Address - City:MONTOUR FALLS
Practice Address - State:NY
Practice Address - Zip Code:14865-9648
Practice Address - Country:US
Practice Address - Phone:607-210-1968
Practice Address - Fax:607-210-1971
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103540-1207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011853200001Medicaid
NYCC8362OtherRR MEDICARE GROUP
NY00368745Medicaid
PA0011853200001Medicaid
NY51425DMedicare ID - Type Unspecified