Provider Demographics
NPI:1619323680
Name:LEIB, MARC
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:
Last Name:LEIB
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:PO BOX 44527
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85064-4527
Mailing Address - Country:US
Mailing Address - Phone:602-708-8455
Mailing Address - Fax:
Practice Address - Street 1:1701 E COLTER ST UNIT 279
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-3379
Practice Address - Country:US
Practice Address - Phone:602-708-8455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15508207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology