Healthcare Provider Details

I. General information

NPI: 1114913274
Provider Name (Legal Business Name): LEOPOLDO S. PARDO III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 04/06/2020
Certification Date: 04/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1667 GOLF COURSE DR
BELLEVILLE IL
62220-4824
US

IV. Provider business mailing address

1667 GOLF COURSE DR
BELLEVILLE IL
62220-4824
US

V. Phone/Fax

Practice location:
  • Phone: 618-257-8017
  • Fax: 618-257-8017
Mailing address:
  • Phone: 618-257-8017
  • Fax: 618-257-8017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036087011
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number036087011
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: