MEDICARE: MRS. LONA LEYBENGRUB RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	005726-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000000119857	OTHER		GHI
2	5318881	OTHER	NY	CIGNA
3	P3621230	OTHER	NY	OXFORD

General Provider Information

NPI Number	:	1326029968
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LONA LEYBENGRUB RD

Provider Business Mailing Address
First Line	:	2651 E 14TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-3915
Country	:	US
Telephone Number	:	347-306-8289
Fax Number	:

Provider Business Practice Location Address
First Line	:	253 MAYBURY AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10308-3251
Country	:	US
Telephone Number	:	347-306-8289
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/10/2005
Last Update Date	:	03/18/2016

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