Healthcare Provider Details

I. General information

NPI: 1346271418
Provider Name (Legal Business Name): LEBER & BANDUCCI PLASTIC SURGERY LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 10/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2807 N FRONT ST
HARRISBURG PA
17110-1222
US

IV. Provider business mailing address

2807 N FRONT ST
HARRISBURG PA
17110-1222
US

V. Phone/Fax

Practice location:
  • Phone: 717-233-4691
  • Fax: 717-233-8836
Mailing address:
  • Phone: 717-233-4691
  • Fax: 717-233-8836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMD-012624-E
License Number StatePA

VIII. Authorized Official

Name: MR. JOHN DALE DEITER
Title or Position: SECRETARY/TREASURER
Credential: MD
Phone: 717-233-4691