Healthcare Provider Details

I. General information

NPI: 1538139324
Provider Name (Legal Business Name): LEONEL CORDOVA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

587 70TH ST
GUTTENBERG NJ
07093-1830
US

IV. Provider business mailing address

587 70TH ST
GUTTENBERG NJ
07093-1830
US

V. Phone/Fax

Practice location:
  • Phone: 786-247-4624
  • Fax:
Mailing address:
  • Phone: 786-247-4624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME94828
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: