Basic Information
| Provider Information | |||||||||
| NPI: | 1992807937 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEON-SMITH | ||||||||
| FirstName: | NILDA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 93 AUTUMN RIDGE | ||||||||
| Address2: | |||||||||
| City: | TRUMBALL | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034451077 | ||||||||
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| Practice Location | |||||||||
| Address1: | 374 GRAND AVE | ||||||||
| Address2: | FAIR HAVEN COMMUNITY HEALTH CTR | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037777411 | ||||||||
| FaxNumber: | 2037778506 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 035885 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 010035885CT01 | 01 | ANTHEM BCBS | OTHER | 00A235763 | 05 | CT | MEDICAID | 035885 9734 | 01 | CONNECTICARE | OTHER | P2742383 | 01 | OXFORD | OTHER |