1003818642 NPI number — MS. KATHLEEN DOLORES VAN LEEUWEN MD

Table of content: MS. KATHLEEN DOLORES VAN LEEUWEN MD (NPI 1003818642)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003818642 NPI number — MS. KATHLEEN DOLORES VAN LEEUWEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN LEEUWEN
Provider First Name:
KATHLEEN
Provider Middle Name:
DOLORES
Provider Name Prefix Text:
MS.
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:
GRAZIANO
Provider Other First Name:
KATHLEEN
Provider Other Middle Name:
DOLORES
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1003818642
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3200 E CAMELBACK RD STE 250
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85018-2327
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-933-1814
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1919 E THOMAS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85016-7710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-933-0016
Provider Business Practice Location Address Fax Number:
602-933-4309
Provider Enumeration Date:
08/12/2005

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: 2086S0120X , with the licence number:  34139 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 940610 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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