Provider Demographics
NPI:1902844046
Name:FITTINGHOFF, LESLIE A (MD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:A
Last Name:FITTINGHOFF
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 1:670 9TH STREET
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-6249
Mailing Address - Country:US
Mailing Address - Phone:707-826-8633
Mailing Address - Fax:707-826-8638
Practice Address - Street 1:2200 TYDD STREET
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-1284
Practice Address - Country:US
Practice Address - Phone:707-269-7051
Practice Address - Fax:707-269-7054
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG72571208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G725710Medicaid
CAF77345Medicare UPIN
CA370008098Medicare PIN
CA00G725710Medicaid