Healthcare Provider Details

I. General information

NPI: 1265435069
Provider Name (Legal Business Name): LEONARD M HALTRECHT D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date: 03/31/2006
Reactivation Date: 07/26/2006

III. Provider practice location address

1999 SPROUL RD STE 21
BROOMALL PA
19008-3508
US

IV. Provider business mailing address

1999 SPROUL RD STE 21
BROOMALL PA
19008-3508
US

V. Phone/Fax

Practice location:
  • Phone: 610-353-5840
  • Fax: 610-353-3420
Mailing address:
  • Phone: 610-353-5840
  • Fax: 610-353-3420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS002378L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: