Provider Demographics
NPI:1528247723
Name:LEO INDIANER, MD, A MEDICAL CORPORATION
Entity type:Organization
Organization Name:LEO INDIANER, MD, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:
Authorized Official - Last Name:INDIANER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661818-788-5216
Mailing Address - Street 1:16260 VENTURA BLVD
Mailing Address - Street 2:SUITE 515
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2203
Mailing Address - Country:US
Mailing Address - Phone:818-788-5216
Mailing Address - Fax:818-788-2702
Practice Address - Street 1:23403 LYONS AVE
Practice Address - Street 2:PMB 178
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-3028
Practice Address - Country:US
Practice Address - Phone:661-799-0368
Practice Address - Fax:661-799-0368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC25642207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A32924Medicare UPIN
CAW6744Medicare PIN