Provider Demographics
NPI:1467503722
Name:LEITZ, EDWARD MARTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:MARTIN
Last Name:LEITZ
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 1:114 VINCENT DR
Mailing Address - Street 2:
Mailing Address - City:STEPHENS CITY
Mailing Address - State:VA
Mailing Address - Zip Code:22655-2354
Mailing Address - Country:US
Mailing Address - Phone:540-683-8742
Mailing Address - Fax:
Practice Address - Street 1:NAVAL BRANCH MEDICAL CLINIC SEWELS POINT
Practice Address - Street 2:1721 TAUSSIG BLVD
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23511
Practice Address - Country:US
Practice Address - Phone:757-953-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101102493207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAH41530Medicare UPIN