Healthcare Provider Details

I. General information

NPI: 1972842680
Provider Name (Legal Business Name): LEONARDO D MOURAO IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2013
Last Update Date: 02/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 PUSAN DR
OCEANSIDE CA
92058-8148
US

IV. Provider business mailing address

1ST MLG 7TH ESB 555677
FPO AP
92055-0000
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-5865
  • Fax:
Mailing address:
  • Phone: 760-725-5865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: