Basic Information
| Provider Information | |||||||||
| NPI: | 1982804241 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HSIAO | ||||||||
| FirstName: | LEAL | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3720 FARRAGUT AVE FL 2 | ||||||||
| Address2: | |||||||||
| City: | KENSINGTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208952152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019494242 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3720 FARRAGUT AVE FL 2 | ||||||||
| Address2: | |||||||||
| City: | KENSINGTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208952152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019494242 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2007 | ||||||||
| LastUpdateDate: | 08/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | C130807 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 243268 | MA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110085418A | 05 | MA | MEDICAID |