Basic Information
| Provider Information | |||||||||
| NPI: | 1588700645 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DELEONARDIS | ||||||||
| FirstName: | EDWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1507 | ||||||||
| Address2: | |||||||||
| City: | TEMPLETON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934651507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054344989 | ||||||||
| FaxNumber: | 8052863820 | ||||||||
| Practice Location | |||||||||
| Address1: | 345 S HALCYON RD | ||||||||
| Address2: | |||||||||
| City: | ARROYO GRANDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934203896 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054894261 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 08/14/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | G44950 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00G449500 | 05 | CA | MEDICAID |