Provider Demographics
NPI:1598702276
Name:TACSA, LEONCIO J (MD)
Entity type:Individual
Prefix:DR
First Name:LEONCIO
Middle Name:J
Last Name:TACSA
Suffix:
Gender:
Credentials:MD
Other - Prefix:DR
Other - First Name:LEONCIO
Other - Middle Name:J
Other - Last Name:TACSA-CARRASCO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:12 PEABODY CT
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-6484
Mailing Address - Country:US
Mailing Address - Phone:201-304-0021
Mailing Address - Fax:
Practice Address - Street 1:12 PEABODY CT
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-6484
Practice Address - Country:US
Practice Address - Phone:201-304-0021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME72300174400000X, 207R00000X, 208M00000X
CT75406208M00000X
NY186353208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No174400000XOther Service ProvidersSpecialist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5533503Medicaid
NJ5533503Medicaid
F64818Medicare UPIN