Healthcare Provider Details

I. General information

NPI: 1215991146
Provider Name (Legal Business Name): LEONIDAS G KONIARIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 UNIVERSITY BLVD
INDIANAPOLIS IN
46202-5149
US

IV. Provider business mailing address

250 N SHADELAND AVE SUITE 130, PROVIDER ENROLLMENT
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-278-7778
  • Fax: 317-274-0241
Mailing address:
  • Phone: 317-963-0860
  • Fax: 317-962-4343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberMD442981
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberME87729
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number01072696A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: