Healthcare Provider Details

I. General information

NPI: 1528176682
Provider Name (Legal Business Name): LEONARDO DISHMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 PARK ST
MALONE NY
12953-1220
US

IV. Provider business mailing address

133 PARK ST
MALONE NY
12953-1220
US

V. Phone/Fax

Practice location:
  • Phone: 518-481-6434
  • Fax: 516-481-2366
Mailing address:
  • Phone: 518-481-6434
  • Fax: 516-481-2366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZB0001X
TaxonomyBlood Banking & Transfusion Medicine Physician
License Number160893
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207ZC0500X
TaxonomyCytopathology Physician
License Number160893
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number160893
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: