Provider Demographics
NPI:1952419830
Name:LEONARD, MARY LISA (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LISA
Last Name:LEONARD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:985 ROBERT BLVD
Mailing Address - Street 2:SUITE101
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-2063
Mailing Address - Country:US
Mailing Address - Phone:985-690-8300
Mailing Address - Fax:985-847-2310
Practice Address - Street 1:985 ROBERT BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2063
Practice Address - Country:US
Practice Address - Phone:985-690-8300
Practice Address - Fax:985-847-2310
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA09276R207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1963046Medicaid
LA1963046Medicaid
LAF52298Medicare UPIN