Provider Demographics
NPI:1063414266
Name:LEITAO-PINA, JAN F (MD)
Entity type:Individual
Prefix:MR
First Name:JAN
Middle Name:F
Last Name:LEITAO-PINA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-3094
Mailing Address - Country:US
Mailing Address - Phone:508-853-8700
Mailing Address - Fax:508-853-8733
Practice Address - Street 1:21 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-3094
Practice Address - Country:US
Practice Address - Phone:508-853-8700
Practice Address - Fax:508-853-8733
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2016-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA79217207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAG45339Medicare UPIN
MAJ18336Medicare ID - Type Unspecified