Provider Demographics
NPI:1649234915
Name:LEOPOLD, MAI P (DO)
Entity Type:Individual
Prefix:
First Name:MAI
Middle Name:P
Last Name:LEOPOLD
Suffix:
Gender:F
Credentials:DO
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 92900
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0900
Mailing Address - Country:US
Mailing Address - Phone:503-659-0880
Mailing Address - Fax:503-513-7425
Practice Address - Street 1:10151 SE SUNNYSIDE RD STE 100
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-5705
Practice Address - Country:US
Practice Address - Phone:503-659-0880
Practice Address - Fax:503-513-7425
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO12247207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR060467Medicaid
WA130904OtherWA LABOR & INDUSTRIES
OR102854Medicare ID - Type Unspecified
C93906Medicare UPIN