Provider Demographics
NPI:1326229485
Name:DPMLEONHEARTPRWA LLC
Entity Type:Organization
Organization Name:DPMLEONHEARTPRWA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:LEONHEART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-841-3668
Mailing Address - Street 1:11201 88TH AVE E
Mailing Address - Street 2:SUITE 210
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-3802
Mailing Address - Country:US
Mailing Address - Phone:253-841-3668
Mailing Address - Fax:253-841-0878
Practice Address - Street 1:10116 116TH ST E
Practice Address - Street 2:SUITE 103
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3543
Practice Address - Country:US
Practice Address - Phone:253-841-3668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000778213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1121714Medicaid
WA5447700001Medicare NSC
U48997Medicare UPIN
WA1121714Medicaid