Provider Demographics
NPI:1114061421
Name:DELEAVER, MARGO PATRICIA (MD)
Entity Type:Individual
Prefix:
First Name:MARGO
Middle Name:PATRICIA
Last Name:DELEAVER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARGO
Other - Middle Name:PATRICIA
Other - Last Name:DELEAVER-RUSSELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3831 HUGHES AVE STE 601
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-6844
Mailing Address - Country:US
Mailing Address - Phone:310-838-4048
Mailing Address - Fax:310-838-0491
Practice Address - Street 1:3831 HUGHES AVE STE 601
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-6844
Practice Address - Country:US
Practice Address - Phone:310-838-4048
Practice Address - Fax:310-838-0491
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC38896208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C388960Medicaid