Healthcare Provider Details

I. General information

NPI: 1578548640
Provider Name (Legal Business Name): LEO DANIEL HURLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR 88 MDG/SGCXE
WRIGHT PATTERSON OH
45433-5546
US

IV. Provider business mailing address

3021 SOUTHFIELD DR
BEAVERCREEK OH
45434-5721
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-1942
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD-047964-L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: