Provider Demographics
NPI:1336217066
Name:LEITSCHUH, MARK LINUS (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:LINUS
Last Name:LEITSCHUH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:4425 N PORT WASHINGTON RD
Mailing Address - Street 2:ATTN: CSMCP CLINIC CREDENTIALING
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1082
Mailing Address - Country:US
Mailing Address - Phone:262-243-3700
Mailing Address - Fax:262-243-3701
Practice Address - Street 1:13133 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 122
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53097-2419
Practice Address - Country:US
Practice Address - Phone:262-243-3700
Practice Address - Fax:262-243-3701
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2012-06-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WI31195207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31602900Medicaid
WI31602900Medicaid
WI000073893Medicare ID - Type Unspecified