Provider Demographics
NPI:1326138355
Name:LEIBOLD, SCOTT HOWARD (DPM)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:HOWARD
Last Name:LEIBOLD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:SCOTT
Other - Middle Name:
Other - Last Name:LEIBOLD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:2107 PICKWICK DR
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-6247
Mailing Address - Country:US
Mailing Address - Phone:805-484-6956
Mailing Address - Fax:805-484-6976
Practice Address - Street 1:2107 PICKWICK DR
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-6427
Practice Address - Country:US
Practice Address - Phone:805-484-6956
Practice Address - Fax:805-484-6976
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4073213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine