Provider Demographics
NPI:1164072187
Name:LEICHTNAM, PETER JOHN
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:JOHN
Last Name:LEICHTNAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W IRONWOOD DR STE 309
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2660
Mailing Address - Country:US
Mailing Address - Phone:509-994-2105
Mailing Address - Fax:
Practice Address - Street 1:1200 W IRONWOOD DR STE 309
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2660
Practice Address - Country:US
Practice Address - Phone:509-994-2105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center