Provider Demographics
NPI:1013177344
Name:LEITZ, EVAN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:MICHAEL
Last Name:LEITZ
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:PO BOX 30750
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27833-0750
Mailing Address - Country:US
Mailing Address - Phone:252-931-7638
Mailing Address - Fax:252-931-7694
Practice Address - Street 1:2101 W ARLINGTON BLVD STE 210
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5758
Practice Address - Country:US
Practice Address - Phone:252-931-7638
Practice Address - Fax:529-317-6942
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD602944602085B0100X, 2085R0202X
ORMD1918042085B0100X, 2085R0202X
NC2022-007582085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0369498OtherL&I-UAOM
WA0369496OtherL&I-TRA KING COUNTY
WA2020312Medicaid
WA0334294OtherL&I-DIAGNOSTIC IMAGING NW
WA0369494OtherL&I-TRA PIERCE COUNTY