Provider Demographics
NPI:1699758276
Name:NADALO, LENNARD (MD)
Entity type:Individual
Prefix:
First Name:LENNARD
Middle Name:
Last Name:NADALO
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 1:1750 NORTH HAMPTON ROAD
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115
Mailing Address - Country:US
Mailing Address - Phone:214-946-4397
Mailing Address - Fax:214-946-4399
Practice Address - Street 1:1441 N BECKLEY AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75203-1201
Practice Address - Country:US
Practice Address - Phone:214-946-4397
Practice Address - Fax:214-946-4399
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE54172085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX39707701Medicaid
TX039707701Medicare PIN
C19761Medicare UPIN
TX81R896Medicare PIN