1710901244 NPI number — DR. LEONA ALICE VELICOV DPM

Table of content: DR. LEONA ALICE VELICOV DPM (NPI 1710901244)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710901244 NPI number — DR. LEONA ALICE VELICOV DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VELICOV
Provider First Name:
LEONA
Provider Middle Name:
ALICE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VELICOV
Provider Other First Name:
LEONA
Provider Other Middle Name:
ALICE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPM
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1710901244
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3445 ST VINCENT ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19149-1627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-338-2444
Provider Business Mailing Address Fax Number:
215-708-5000

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3445 ST VINCENT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19149-1627
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-338-2444
Provider Business Practice Location Address Fax Number:
215-708-5000
Provider Enumeration Date:
07/27/2006

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: 213E00000X , with the licence number:  SC001964L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0060668000 . This is a "BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 007047608-0006 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 007047608-0004 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 007047608-0005 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 007047608-0008 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 007047608-0009 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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