=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851352058
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DOMENICO LEUCI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2006
-----------------------------------------------------
Last Update Date | 04/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 365 HARRY L DR STE 110
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13790-1471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-729-5805
-----------------------------------------------------
Fax | 607-729-7714
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 365 HARRY L DR STE 110
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13790-1471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-754-9870
-----------------------------------------------------
Fax | 607-785-9862
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 232736
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------