Basic Information
| Provider Information | |||||||||
| NPI: | 1376769984 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEONARD | ||||||||
| FirstName: | RAYMOND | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 217 | ||||||||
| Address2: | |||||||||
| City: | ROCK CAVE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 262340217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049246262 | ||||||||
| FaxNumber: | 3049245460 | ||||||||
| Practice Location | |||||||||
| Address1: | ROUTE 4 & 20 S. INTERSECTION | ||||||||
| Address2: | |||||||||
| City: | ROCK CAVE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 262340217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3049246262 | ||||||||
| FaxNumber: | 3049245460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2007 | ||||||||
| LastUpdateDate: | 03/24/2010 | ||||||||
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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 | 208000000X | 23057 | WV | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 3810012261 | 05 | WV | MEDICAID |