Healthcare Provider Details

I. General information

NPI: 1457342255
Provider Name (Legal Business Name): LEO F KENZAKOWSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 09/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 SKIPWITH RD
RICHMOND VA
23229-5205
US

IV. Provider business mailing address

4050 INNSLAKE DR SUITE 308
GLEN ALLEN VA
23060-3327
US

V. Phone/Fax

Practice location:
  • Phone: 804-289-4500
  • Fax:
Mailing address:
  • Phone: 804-521-5315
  • Fax: 804-521-5312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101233641
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101233641
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: