Provider Demographics
NPI:1083683056
Name:BUNUEL-JORDANA, LEO R (DO)
Entity type:Individual
Prefix:
First Name:LEO
Middle Name:R
Last Name:BUNUEL-JORDANA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 HARVARD WAY
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-2055
Mailing Address - Country:US
Mailing Address - Phone:775-982-5262
Mailing Address - Fax:775-982-5496
Practice Address - Street 1:1155 MILL ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-1576
Practice Address - Country:US
Practice Address - Phone:775-982-7878
Practice Address - Fax:775-982-4196
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1162207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1083683056Medicaid
11328955OtherCAQH
NVCJ006YMedicare PIN
H84711Medicare UPIN
NV1083683056Medicaid