Provider Demographics
NPI:1013044254
Name:LEIST, FREDERICK D (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:D
Last Name:LEIST
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 CHERRY AVENUE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310
Mailing Address - Country:US
Mailing Address - Phone:360-479-4370
Mailing Address - Fax:360-792-1166
Practice Address - Street 1:2600 CHERRY AVENUE
Practice Address - Street 2:SUITE 201
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310
Practice Address - Country:US
Practice Address - Phone:360-479-4370
Practice Address - Fax:360-792-1166
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000109792086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
A06955Medicare UPIN
WAGAB21428Medicare PIN
WAGAB21428Medicare ID - Type Unspecified