Provider Demographics
NPI:1831970763
Name:ACEVEDO, LEIDY
Entity type:Individual
Prefix:
First Name:LEIDY
Middle Name:
Last Name:ACEVEDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 TETERBORO LANDING DR
Mailing Address - Street 2:
Mailing Address - City:TETERBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:07608-1120
Mailing Address - Country:US
Mailing Address - Phone:201-375-4005
Mailing Address - Fax:
Practice Address - Street 1:1 TETERBORO LANDING DR
Practice Address - Street 2:
Practice Address - City:TETERBORO
Practice Address - State:NJ
Practice Address - Zip Code:07608-1120
Practice Address - Country:US
Practice Address - Phone:201-375-4005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-06
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJTD-4195156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician