Provider Demographics
NPI:1548367238
Name:DENATALE, LEO CARL JR (OD)
Entity type:Individual
Prefix:
First Name:LEO
Middle Name:CARL
Last Name:DENATALE
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 TRAPELO RD
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478
Mailing Address - Country:US
Mailing Address - Phone:617-484-4851
Mailing Address - Fax:617-484-4852
Practice Address - Street 1:334 TRAPELO RD
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478
Practice Address - Country:US
Practice Address - Phone:617-484-4851
Practice Address - Fax:617-484-4852
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2899152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0343668Medicaid
MA199158Medicare ID - Type Unspecified
MA0343668Medicaid