=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922166743
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEO H MAHONY JR. DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2006
-----------------------------------------------------
Last Update Date | 04/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8901 WISCONSIN AVENUE AMERICA BUILDING (BLDG 19) 1/F
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20889-5650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-319-7048
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 W HOSPITAL ROAD EISENHOWER ARMY MEDICAL CENTER ATTN CREDENTIALS
-----------------------------------------------------
City | FORT GORDON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30905-5650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-787-2720
-----------------------------------------------------
Fax | 706-787-8176
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | 7905
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number | 23792
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------