Provider Demographics
NPI:1629073598
Name:REDAL, LEIF A (MD)
Entity Type:Individual
Prefix:
First Name:LEIF
Middle Name:A
Last Name:REDAL
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 1:8097 HARBORVIEW RD
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:WA
Mailing Address - Zip Code:98230-9639
Mailing Address - Country:US
Mailing Address - Phone:360-371-5855
Mailing Address - Fax:360-371-5857
Practice Address - Street 1:511 CROSSING DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-2628
Practice Address - Country:US
Practice Address - Phone:303-269-2875
Practice Address - Fax:303-269-2876
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00027907207Q00000X
CODR.0030471207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04389832Medicaid
B18284Medicare UPIN
COP00925822Medicare PIN
COCOA105337Medicare PIN