1902844046 NPI number — DR. LESLIE A FITTINGHOFF MD

Table of content: DR. LESLIE A FITTINGHOFF MD (NPI 1902844046)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902844046 NPI number — DR. LESLIE A FITTINGHOFF MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FITTINGHOFF
Provider First Name:
LESLIE
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902844046
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
670 9TH STREET
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
ARCATA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95521-6249
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-826-8633
Provider Business Mailing Address Fax Number:
707-826-8638

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 TYDD STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUREKA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95501-1284
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-269-7051
Provider Business Practice Location Address Fax Number:
707-269-7054
Provider Enumeration Date:
06/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  G72571 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00G725710 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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