=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730453440
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EFREN LEONIDA MD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2012
-----------------------------------------------------
Last Update Date | 02/27/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 BRADDOCK ROAD AVE SUITE A
-----------------------------------------------------
City | MT PLEASANT
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15666-1458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-547-4565
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 BRADDOCK ROAD AVE SUITE A
-----------------------------------------------------
City | MT PLEASANT
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15666-1458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-547-4565
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL SECRETARY
-----------------------------------------------------
Name | MS. MARLA K VINKLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 724-547-4565
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD034778L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------