Provider Demographics
NPI:1619928249
Name:MASTBAUM, LEONARD I (MD)
Entity type:Individual
Prefix:
First Name:LEONARD
Middle Name:I
Last Name:MASTBAUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1234 E DUPONT RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-9700
Mailing Address - Fax:260-373-9740
Practice Address - Street 1:11123 PARKVIEW PLAZA DR
Practice Address - Street 2:SUITE 202
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1707
Practice Address - Country:US
Practice Address - Phone:260-373-4280
Practice Address - Fax:260-373-4288
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2013-03-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01041346207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100360850Medicaid
IN000000606758OtherANTHEM
IN925060MMedicare ID - Type Unspecified
IN100360850Medicaid
IN070860C1Medicare PIN