Provider Demographics
NPI:1225068372
Name:LEITAO, MARIO MENDES JR (MD)
Entity type:Individual
Prefix:
First Name:MARIO
Middle Name:MENDES
Last Name:LEITAO
Suffix:JR
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 1:1275 YORK AVE # H1314
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-6007
Mailing Address - Country:US
Mailing Address - Phone:646-620-2438
Mailing Address - Fax:
Practice Address - Street 1:1275 YORK AVE # H1314
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-6007
Practice Address - Country:US
Practice Address - Phone:212-639-3987
Practice Address - Fax:212-717-3709
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07727200207VX0201X
NY208249207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0043800Medicaid
NJ086050Medicare ID - Type Unspecified
NJ0043800Medicaid