Basic Information
| Provider Information | |||||||||
| NPI: | 1093774978 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PASTULA | ||||||||
| FirstName: | LEONARD | ||||||||
| MiddleName: | T. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 CARLISLE DR | ||||||||
| Address2: | |||||||||
| City: | GLEN HEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115452120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9178852706 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 BELLE TERRE RD | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117771928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314746000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2006 | ||||||||
| LastUpdateDate: | 03/29/2011 | ||||||||
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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 | 207P00000X | 215143 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02199668 | 05 | NY | MEDICAID | 1652Q1 | 01 | NY | BLUECROSS BLUESHIELD | OTHER |