Provider Demographics
NPI:1003818642
Name:VAN LEEUWEN, KATHLEEN DOLORES (MD)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:DOLORES
Last Name:VAN LEEUWEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:KATHLEEN
Other - Middle Name:DOLORES
Other - Last Name:GRAZIANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3200 E CAMELBACK RD STE 250
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2327
Mailing Address - Country:US
Mailing Address - Phone:602-933-1814
Mailing Address - Fax:
Practice Address - Street 1:1919 E THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7710
Practice Address - Country:US
Practice Address - Phone:602-933-0016
Practice Address - Fax:602-933-4309
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ341392086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ940610Medicaid
AZ94061003Medicare PIN
AZ940610Medicaid