Provider Demographics
NPI:1386816692
Name:LEISZLER, MATTHEW SCOTT
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:SCOTT
Last Name:LEISZLER
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 1:101 ST LIAM HALL
Mailing Address - Street 2:
Mailing Address - City:NOTRE DAME
Mailing Address - State:IN
Mailing Address - Zip Code:46556-5693
Mailing Address - Country:US
Mailing Address - Phone:574-631-7497
Mailing Address - Fax:
Practice Address - Street 1:101 ST LIAM HALL
Practice Address - Street 2:
Practice Address - City:NOTRE DAME
Practice Address - State:IN
Practice Address - Zip Code:46556-5693
Practice Address - Country:US
Practice Address - Phone:574-631-7497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-26
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01074692A207Q00000X
CO48096207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO92430813Medicaid
COCOA108591Medicare PIN