Provider Demographics
NPI:1508810185
Name:LEISTIKO, LAURA L (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:L
Last Name:LEISTIKO
Suffix:
Gender:F
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:PO BOX 662154
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91066-2154
Mailing Address - Country:US
Mailing Address - Phone:626-447-0296
Mailing Address - Fax:626-447-6057
Practice Address - Street 1:2975 SYCAMORE DR
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1201
Practice Address - Country:US
Practice Address - Phone:805-955-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90865207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A908650Medicaid
CA00A908650Medicaid