Provider Demographics
NPI:1497847388
Name:KIZILBASH, LEENA FATIMA (MD)
Entity type:Individual
Prefix:
First Name:LEENA
Middle Name:FATIMA
Last Name:KIZILBASH
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 1:22 HAYDEN ST
Mailing Address - Street 2:
Mailing Address - City:ROXBURY CROSSING
Mailing Address - State:MA
Mailing Address - Zip Code:02120-3376
Mailing Address - Country:US
Mailing Address - Phone:312-953-2839
Mailing Address - Fax:
Practice Address - Street 1:1826 VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-3620
Practice Address - Country:US
Practice Address - Phone:800-562-8663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH129662084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine