Healthcare Provider Details

I. General information

NPI: 1215129085
Provider Name (Legal Business Name): TICIANA B LEAL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2007
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1364 CLIFTON RD NE
ATLANTA GA
30322-1914
US

IV. Provider business mailing address

1364 CLIFTON RD NE
ATLANTA GA
30322-1059
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-3313
  • Fax:
Mailing address:
  • Phone: 404-778-3313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number89952
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number50297
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number50297
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: