Provider Demographics
NPI:1316907082
Name:LEONI, PETER VINCENT (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:VINCENT
Last Name:LEONI
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:PO BOX 590
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94953-0590
Mailing Address - Country:US
Mailing Address - Phone:707-781-6926
Mailing Address - Fax:707-762-2145
Practice Address - Street 1:1116 B ST
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-4054
Practice Address - Country:US
Practice Address - Phone:707-781-6926
Practice Address - Fax:707-762-2145
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-25
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64218208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G642180Medicaid
CA0699619Medicaid
CA00G642180Medicaid
CA0699619Medicaid