Healthcare Provider Details

I. General information

NPI: 1831105568
Provider Name (Legal Business Name): LEONARDO MARIO CANESSA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 12/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PLZ
DAYTON OH
45404-1898
US

IV. Provider business mailing address

1 CHILDRENS PLZ
DAYTON OH
45404-1898
US

V. Phone/Fax

Practice location:
  • Phone: 937-641-3304
  • Fax: 937-641-4600
Mailing address:
  • Phone: 937-641-3304
  • Fax: 937-641-4600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number35.068720
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: