Provider Demographics
NPI:1689199317
Name:LEITZEL, CHRISTINA N (BS BCO BADO)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:N
Last Name:LEITZEL
Suffix:
Gender:F
Credentials:BS BCO BADO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2456 NW NORTHRUP ST STE 1A
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3253
Mailing Address - Country:US
Mailing Address - Phone:503-229-8490
Mailing Address - Fax:
Practice Address - Street 1:2456 NW NORTHRUP ST STE 1A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3253
Practice Address - Country:US
Practice Address - Phone:503-229-8490
Practice Address - Fax:503-224-0740
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-03
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
335E00000X
OR156FX1700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR01621900001OtherREGENCE
OR7760590001OtherMEDICARE
OR500647964OtherOMAP