Healthcare Provider Details

I. General information

NPI: 1194285072
Provider Name (Legal Business Name): LEONARDO TJAHJONO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7500 GREENWAY CENTER DR STE 1220
GREENBELT MD
20770-3590
US

IV. Provider business mailing address

1321 RHODE ISLAND AVE NW APT 2
WASHINGTON DC
20005-4871
US

V. Phone/Fax

Practice location:
  • Phone: 301-615-1986
  • Fax: 301-200-8767
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number0101277702
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD600004150
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: