Basic Information
| Provider Information | |||||||||
| NPI: | 1033165642 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHINGLEDECKER | ||||||||
| FirstName: | LEON | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8101 HINSON FARM RD | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223063403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037654321 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8101 HINSON FARM RD | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223063403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037654321 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 04/08/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 0103001046 | VA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | SC002084L | PA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | 200007 | LA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 9300619 | 05 | VA | MEDICAID |