Provider Demographics
NPI:1316419757
Name:COLON, LEONARDO
Entity type:Individual
Prefix:
First Name:LEONARDO
Middle Name:
Last Name:COLON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 BENEFIT ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01610-1566
Mailing Address - Country:US
Mailing Address - Phone:617-510-4055
Mailing Address - Fax:
Practice Address - Street 1:20 BENEFIT ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-1566
Practice Address - Country:US
Practice Address - Phone:617-510-4055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-26
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS13982805172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver