Provider Demographics
NPI:1689399339
Name:LEISS, DEREK ALEXANDER (ND)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:ALEXANDER
Last Name:LEISS
Suffix:
Gender:M
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2722 NE 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3302
Mailing Address - Country:US
Mailing Address - Phone:480-262-6466
Mailing Address - Fax:
Practice Address - Street 1:819 SE MORRISON ST STE 115
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-6308
Practice Address - Country:US
Practice Address - Phone:503-956-9396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-05
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4474175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty