Provider Demographics
NPI:1013071612
Name:LEISAWITZ, ELLIOTT G (MD)
Entity Type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:G
Last Name:LEISAWITZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-3335
Mailing Address - Country:US
Mailing Address - Phone:610-372-8044
Mailing Address - Fax:610-371-0310
Practice Address - Street 1:1020 GRINGS HILL RD
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19608-8844
Practice Address - Country:US
Practice Address - Phone:610-898-5030
Practice Address - Fax:610-777-3474
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD015371E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000715191Medicaid
PAB37093Medicare UPIN
PA000715191Medicaid