Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | 036.129240 | IL |
N | 207N00000X | Dermatologist | 54438 | WI |
N | 207ND0101X | MOHS-Micrographic Surgeon | 036.129240 | IL |
NPI | 1255523296 |
---|---|
Provider Name | Dr. Douglas Michael Leone |
First Address | Bloomington, IL 61704-5402 |
Second Address | Bloomington, IL 61704-5402 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/08/2007 |
Last Update Date | 29/09/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036129240 | (05) | IL |
1255523296 | (05) | WI |