Basic Information
| Provider Information | |||||||||
| NPI: | 1750351888 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PITTALA | ||||||||
| FirstName: | LEONARD | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 CORONA RD | ||||||||
| Address2: | STE 102 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652032582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732341800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2101 CORONA RD | ||||||||
| Address2: | STE 102 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652032582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5732341800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 01/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | R6A65 | MO | N | Allopathic & Osteopathic Physicians | Pediatrics | 208D00000X | R6A65 | MO | Y | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 241705904 | 05 | MO | MEDICAID | 09731015 | 01 | MO | BCBS OF KANSAS CITY INDIV | OTHER |