Healthcare Provider Details

I. General information

NPI: 1902931504
Provider Name (Legal Business Name): LEONARDO T QUE MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 E 6TH ST SUITE D
PORT CLINTON OH
43452-2065
US

IV. Provider business mailing address

602 E 6TH ST SUITE D
PORT CLINTON OH
43452-2065
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: DR. LEONARDO T QUE
Title or Position: OFFICE
Credential: M.D.
Phone: 419-734-4539