Provider Demographics
NPI:1063437275
Name:LEONDIRES, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LEONDIRES
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 1:761 MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-1080
Mailing Address - Country:US
Mailing Address - Phone:203-750-7400
Mailing Address - Fax:
Practice Address - Street 1:761 MAIN AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-1080
Practice Address - Country:US
Practice Address - Phone:203-750-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040142207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G00379Medicare UPIN