1205920980 NPI number — DR. ELISE EGERTER LEONARD MD

Table of content: MELISSA NOLAN (NPI 1003531575)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205920980 NPI number — DR. ELISE EGERTER LEONARD MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEONARD
Provider First Name:
ELISE
Provider Middle Name:
EGERTER
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:
1205920980
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 31001-0698
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91110-0698
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-263-1511
Provider Business Mailing Address Fax Number:
602-263-1637

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4212 N. 16TH ST.
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:
85016-5319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-263-1511
Provider Business Practice Location Address Fax Number:
602-263-1637
Provider Enumeration Date:
10/03/2006

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: 2084P0800X , with the licence number:  24161 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0804X , with the licence number: 24161 , 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: AZ0787300 . This is a "BCBS" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 946634 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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