Healthcare Provider Details

I. General information

NPI: 1659057818
Provider Name (Legal Business Name): LEOR SURILOV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2023
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 WELLS ST
WESTERLY RI
02891-2922
US

IV. Provider business mailing address

1643 NW 136TH AVE # H-100
SUNRISE FL
33323-3091
US

V. Phone/Fax

Practice location:
  • Phone: 401-348-3670
  • Fax:
Mailing address:
  • Phone: 954-377-2939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number84037
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: