Provider Demographics
NPI:1437241874
Name:LEISTIKOW, DAVID C (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:C
Last Name:LEISTIKOW
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 1:1022 DEPOT HILL RD
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-1068
Mailing Address - Country:US
Mailing Address - Phone:303-465-2323
Mailing Address - Fax:303-465-1260
Practice Address - Street 1:1022 DEPOT HILL RD
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-1068
Practice Address - Country:US
Practice Address - Phone:303-465-2323
Practice Address - Fax:303-465-1260
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO17659207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01176593Medicaid
CO01176593Medicaid
COD23320Medicare UPIN