=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962694919
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEONARD M. ZULLO,M.D.P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2007
-----------------------------------------------------
Last Update Date | 08/14/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1665 MERRITT BLVD
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21222-2117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-282-5330
-----------------------------------------------------
Fax | 410-282-2924
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1665 MERRITT BLVD
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21222-2117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-282-5330
-----------------------------------------------------
Fax | 410-282-2924
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. LEONARD MICHAEL ZULLO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 410-282-5330
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | D0011312
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------