Basic Information
| Provider Information | |||||||||
| NPI: | 1356346258 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | QUE | ||||||||
| FirstName: | LEONARDO | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 FULTON ST | ||||||||
| Address2: | SUITE E | ||||||||
| City: | PORT CLINTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197344539 | ||||||||
| FaxNumber: | 4197346365 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 FULTON ST | ||||||||
| Address2: | SUITE E | ||||||||
| City: | PORT CLINTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 434522008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197344539 | ||||||||
| FaxNumber: | 4197346365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 10/06/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 35-05-0504 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 0584309 | 05 | OH | MEDICAID |