Healthcare Provider Details

I. General information

NPI: 1356346258
Provider Name (Legal Business Name): LEONARDO T QUE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 10/06/2020
Certification Date: 10/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 FULTON ST SUITE E
PORT CLINTON OH
43452-2008
US

IV. Provider business mailing address

611 FULTON ST SUITE E
PORT CLINTON OH
43452
US

V. Phone/Fax

Practice location:
  • Phone: 419-734-4539
  • Fax: 419-734-6365
Mailing address:
  • Phone: 419-734-4539
  • Fax: 419-734-6365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35-05-0504
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: