1457342255 NPI number — MR. LEO F KENZAKOWSKI MD

Table of content: MR. LEO F KENZAKOWSKI MD (NPI 1457342255)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457342255 NPI number — MR. LEO F KENZAKOWSKI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KENZAKOWSKI
Provider First Name:
LEO
Provider Middle Name:
F
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457342255
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4050 INNSLAKE DR
Provider Second Line Business Mailing Address:
SUITE 308
Provider Business Mailing Address City Name:
GLEN ALLEN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23060-3327
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
804-521-5315
Provider Business Mailing Address Fax Number:
804-521-5312

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1602 SKIPWITH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHMOND
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23229-5205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
804-289-4500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  0101233641 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: 0101233641 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6230121 . This is a "CIGNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 10228905 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1457342255 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 302011 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: P00601102 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 10228905 . This is a "ANTHEM" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: P00606712 . This is a "RR MEDICARE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 631615 . This is a "SOUTHERN HEALTH" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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