Healthcare Provider Details

I. General information

NPI: 1255523296
Provider Name (Legal Business Name): DOUGLAS MICHAEL LEONE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 BUSINESS PARK DR STE C
BRANSON MO
65616-7449
US

IV. Provider business mailing address

110 BUSINESS PARK DR STE C
BRANSON MO
65616-7449
US

V. Phone/Fax

Practice location:
  • Phone: 417-336-0033
  • Fax: 309-452-3376
Mailing address:
  • Phone: 417-336-0033
  • Fax: 855-710-6552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number54438
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036.129240
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number333863
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number036.129240
License Number StateIL
# 5
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2022035062
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: