Provider Demographics
NPI:1982011243
Name:SHAFFOLD, LEON
Entity Type:Individual
Prefix:
First Name:LEON
Middle Name:
Last Name:SHAFFOLD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12600 ROCKSIDE RD
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-4525
Mailing Address - Country:US
Mailing Address - Phone:216-510-4984
Mailing Address - Fax:
Practice Address - Street 1:12600 ROCKSIDE RD
Practice Address - Street 2:
Practice Address - City:GARFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44125-4525
Practice Address - Country:US
Practice Address - Phone:216-510-4984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-18
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH188735343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3148338Medicaid