Provider Demographics
NPI:1952340077
Name:LEO, NICOLE (DO)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LEO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 W ROOSEVELT BLVD STE 11&12
Mailing Address - Street 2:
Mailing Address - City:MARMORA
Mailing Address - State:NJ
Mailing Address - Zip Code:08223-1441
Mailing Address - Country:US
Mailing Address - Phone:609-390-0882
Mailing Address - Fax:609-390-3511
Practice Address - Street 1:4 W ROOSEVELT BLVD STE 11&12
Practice Address - Street 2:
Practice Address - City:MARMORA
Practice Address - State:NJ
Practice Address - Zip Code:08223-1441
Practice Address - Country:US
Practice Address - Phone:609-814-9550
Practice Address - Fax:609-390-3511
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07318600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0324248Medicaid
NJ7305463OtherAETNA PPO #
NJ2K8776OtherHEALTHNET #
NJP00232642OtherRAILROAD MCR #
NJ2235657000OtherAMERIHEALTH #
NJ3206835OtherAETNA HMO #
NJ185183OtherAMERIGROUP #
NJP2938592OtherOXFORD ID #
NJP2938592OtherOXFORD ID #
NJH84588Medicare UPIN