Provider Demographics
NPI:1881643724
Name:ETTEFAGH, LEILA (MD)
Entity Type:Individual
Prefix:DR
First Name:LEILA
Middle Name:
Last Name:ETTEFAGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 SAN MIGUEL DR
Mailing Address - Street 2:SUITE 501
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7853
Mailing Address - Country:US
Mailing Address - Phone:949-720-1170
Mailing Address - Fax:949-720-1172
Practice Address - Street 1:360 SAN MIGUEL DR
Practice Address - Street 2:SUITE 501
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7853
Practice Address - Country:US
Practice Address - Phone:949-720-1170
Practice Address - Fax:949-720-1172
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89632207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA89632AMedicare ID - Type Unspecified
CAI33490Medicare UPIN