Healthcare Provider Details

I. General information

NPI: 1932685088
Provider Name (Legal Business Name): NICHOLAS DE LEO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 NEWMAN SPRINGS RD
RED BANK NJ
07701-5688
US

IV. Provider business mailing address

331 NEWMAN SPRINGS RD
RED BANK NJ
07701-5688
US

V. Phone/Fax

Practice location:
  • Phone: 833-615-2618
  • Fax: 732-747-8720
Mailing address:
  • Phone: 833-615-2618
  • Fax: 732-747-8720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number161628
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number25MA11389900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: