Provider Demographics
NPI:1538201231
Name:LEDDY, VINCENT RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:RICHARD
Last Name:LEDDY
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 1:160 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-4610
Mailing Address - Country:US
Mailing Address - Phone:631-273-7105
Mailing Address - Fax:631-273-7253
Practice Address - Street 1:160 4TH ST
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717-4610
Practice Address - Country:US
Practice Address - Phone:631-273-7105
Practice Address - Fax:631-273-7253
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY152061207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY44D851Medicare ID - Type Unspecified
NYB14717Medicare UPIN
NYA100030330Medicare PIN