Provider Demographics
NPI:1417087073
Name:LEISH, BRIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:LEISH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24411 HEALTH CENTER DR
Mailing Address - Street 2:SUITE 460
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3687
Mailing Address - Country:US
Mailing Address - Phone:949-373-7799
Mailing Address - Fax:
Practice Address - Street 1:24411 HEALTH CENTER DR
Practice Address - Street 2:SUITE 460
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3687
Practice Address - Country:US
Practice Address - Phone:949-373-7799
Practice Address - Fax:949-334-8377
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG58832207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG58832P47Medicaid
CAG58832P47Medicaid
CAF57099Medicare UPIN