Provider Demographics
NPI:1902148380
Name:VYDRO, LEONID (MD)
Entity Type:Individual
Prefix:DR
First Name:LEONID
Middle Name:
Last Name:VYDRO
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 1:1 SPRINGFIELD AVE STE 1A
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901-4055
Mailing Address - Country:US
Mailing Address - Phone:908-273-8300
Mailing Address - Fax:908-273-8807
Practice Address - Street 1:1 SPRINGFIELD AVE STE 1A
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-4055
Practice Address - Country:US
Practice Address - Phone:908-273-8300
Practice Address - Fax:908-273-8807
Is Sole Proprietor?:No
Enumeration Date:2013-03-22
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA11150600207RE0101X
IL036140027208M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program