Provider Demographics
NPI:1982793741
Name:WOLANSKY, LEO JOHN (MD)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:JOHN
Last Name:WOLANSKY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LEO
Other - Middle Name:IVAN (JOHN)
Other - Last Name:WOLANSKY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:UCONN MEDICAL GROUP
Mailing Address - Street 2:263 FARMINGTON AVENUE
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-1714
Mailing Address - Country:US
Mailing Address - Phone:860-679-2784
Mailing Address - Fax:860-679-3145
Practice Address - Street 1:UCONN MEDICAL GROUP
Practice Address - Street 2:263 FARMINGTON AVENUE
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-1714
Practice Address - Country:US
Practice Address - Phone:860-679-2784
Practice Address - Fax:860-679-3145
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0992752085B0100X, 2085N0700X, 2085R0202X, 2085R0202X
CT0299442085R0202X
NJ25MA054812002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0074245Medicaid
OHH128131Medicare PIN