Provider Demographics
NPI:1073811857
Name:LANCE G. LEITHAUSER, M D P A
Entity Type:Organization
Organization Name:LANCE G. LEITHAUSER, M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:G
Authorized Official - Last Name:LEITHAUSER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-294-9400
Mailing Address - Street 1:9715 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 535
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3320
Mailing Address - Country:US
Mailing Address - Phone:301-294-9400
Mailing Address - Fax:301-294-0149
Practice Address - Street 1:9715 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 535
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3320
Practice Address - Country:US
Practice Address - Phone:301-294-9400
Practice Address - Fax:301-294-0149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-03
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0021581208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD189061100Medicaid
MDB94611Medicare UPIN