Provider Demographics
NPI:1265435069
Name:HALTRECHT, LEONARD M (DO)
Entity type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:M
Last Name:HALTRECHT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1999 SPROUL RD
Mailing Address - Street 2:STE 21
Mailing Address - City:BROOMALL
Mailing Address - State:PA
Mailing Address - Zip Code:19008-3508
Mailing Address - Country:US
Mailing Address - Phone:610-353-5840
Mailing Address - Fax:610-353-3420
Practice Address - Street 1:1999 SPROUL RD
Practice Address - Street 2:STE 21
Practice Address - City:BROOMALL
Practice Address - State:PA
Practice Address - Zip Code:19008-3508
Practice Address - Country:US
Practice Address - Phone:610-353-5840
Practice Address - Fax:610-353-3420
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2008-04-08
Deactivation Date:2006-03-31
Deactivation Code:
Reactivation Date:2006-07-26
Provider Licenses
StateLicense IDTaxonomies
PAOS002378L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0007336180001Medicaid
PA0032051001OtherKEYSTONE
PA6548OtherAETNA
PA041839OtherBLUE SHIELD
PA041839OtherBLUE SHIELD
PA041839Medicare PIN