Basic Information
| Provider Information | |||||||||
| NPI: | 1427149327 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CONCHA LEON | ||||||||
| FirstName: | ALONSO | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E PENN SQ | ||||||||
| Address2: | 9TH FL | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191073323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2674259234 | ||||||||
| FaxNumber: | 2674259299 | ||||||||
| Practice Location | |||||||||
| Address1: | 1925 PACIFIC AVE | ||||||||
| Address2: | |||||||||
| City: | ATLANTIC CITY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 084016713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6093454000 | ||||||||
| FaxNumber: | 6095728523 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 12/02/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 25MA08140100 | NJ | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | MD429937 | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1020803440008 | 05 | PA | MEDICAID |