Provider Demographics
NPI:1538480603
Name:BASILICO, LEOPOLDO MARIO (MD)
Entity type:Individual
Prefix:
First Name:LEOPOLDO
Middle Name:MARIO
Last Name:BASILICO
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:PO BOX 276950
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-6950
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL PLAZA DR
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3037
Practice Address - Country:US
Practice Address - Phone:916-733-3777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-11
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA152830207R00000X, 208M00000X
TN50850207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist