Provider Demographics
NPI:1619402609
Name:LEON VELARDE CARRENO, ERNESTO (MD)
Entity type:Individual
Prefix:
First Name:ERNESTO
Middle Name:
Last Name:LEON VELARDE CARRENO
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 1:462 GRIDER ST STE 1152
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-3021
Mailing Address - Country:US
Mailing Address - Phone:716-898-4803
Mailing Address - Fax:
Practice Address - Street 1:462 GRIDER ST STE 1152
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-3021
Practice Address - Country:US
Practice Address - Phone:716-898-4803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-27
Last Update Date:2025-08-28
Deactivation Date:2017-11-29
Deactivation Code:
Reactivation Date:2018-10-04
Provider Licenses
StateLicense IDTaxonomies
AZ64329207RN0300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ124036Medicaid