MEDICARE: MR. DAVID JOHN LEANDRO C.PED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor	9914	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	L937	OTHER	GA	KAISER PERMANENTE

General Provider Information

NPI Number	:	1053317867
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID JOHN LEANDRO C.PED

Provider Business Mailing Address
First Line	:	4814 DELGADO DR SW
Second Line	:
City	:	LILBURN
State	:	GA
Zip	:	30047-5204
Country	:	US
Telephone Number	:	770-931-0823
Fax Number	:	678-205-1738

Provider Business Practice Location Address
First Line	:	4760 LAWRENCEVILLE HWY NW
Second Line	:	SUITE C-1
City	:	LILBURN
State	:	GA
Zip	:	30047-3858
Country	:	US
Telephone Number	:	770-921-4480
Fax Number	:	678-205-1738

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	07/08/2007

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