Provider Demographics
NPI:1205006186
Name:HICE, LETA A (MD)
Entity Type:Individual
Prefix:DR
First Name:LETA
Middle Name:A
Last Name:HICE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LETA
Other - Middle Name:A
Other - Last Name:HOUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2020 N CENTRAL AVE
Mailing Address - Street 2:SUITE 1010
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-4501
Mailing Address - Country:US
Mailing Address - Phone:602-553-8400
Mailing Address - Fax:602-553-8408
Practice Address - Street 1:2020 N CENTRAL AVE
Practice Address - Street 2:SUITE 1010
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-4501
Practice Address - Country:US
Practice Address - Phone:602-553-8400
Practice Address - Fax:602-553-8408
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ390200000X
AZ40380207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ336597Medicaid
AZ1205006186Medicare PIN