Healthcare Provider Details

I. General information

NPI: 1558330829
Provider Name (Legal Business Name): LEONARD MATTANO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 JOHN ST STE E-300
KALAMAZOO MI
49007-5341
US

IV. Provider business mailing address

1000 OAKLAND DR
KALAMAZOO MI
49008-1282
US

V. Phone/Fax

Practice location:
  • Phone: 269-341-6350
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number4301405921
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: