Provider Demographics
NPI:1215991146
Name:KONIARIS, LEONIDAS G (MD)
Entity type:Individual
Prefix:
First Name:LEONIDAS
Middle Name:G
Last Name:KONIARIS
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:SUITE 130, PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:317-963-0860
Mailing Address - Fax:317-962-4343
Practice Address - Street 1:550 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5149
Practice Address - Country:US
Practice Address - Phone:317-278-7778
Practice Address - Fax:317-274-0241
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4429812086X0206X
FLME877292086X0206X
IN01072696A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201208380Medicaid
FL2678489-00Medicaid
IN233690018Medicare PIN
INP01297746Medicare PIN
FL81374Medicare ID - Type Unspecified
FLF91267Medicare UPIN