Basic Information
| Provider Information | |||||||||
| NPI: | 1750456406 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARIE LAURA LEON M.D P.C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 441 9TH AVE | ||||||||
| Address2: | ACP CREDENTIALING OFFICE - 3RD FLOOR | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100011623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6466802894 | ||||||||
| FaxNumber: | 5165425556 | ||||||||
| Practice Location | |||||||||
| Address1: | 391 EASTERN PKWY | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112164153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186131600 | ||||||||
| FaxNumber: | 7186131666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 02/09/2016 | ||||||||
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| AuthorizedOfficialLastName: | SIMPSON | ||||||||
| AuthorizedOfficialFirstName: | MARLENA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6466802894 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPMSM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | 196577 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01682782 | 05 | NY | MEDICAID |