Provider Demographics
NPI:1669445706
Name:DRISS, LEON A (MD)
Entity type:Individual
Prefix:
First Name:LEON
Middle Name:A
Last Name:DRISS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5300 S SUTTER DR STE 12
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-8055
Mailing Address - Country:US
Mailing Address - Phone:928-251-2541
Mailing Address - Fax:833-450-5183
Practice Address - Street 1:5300 S SUTTER DR STE 12
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-8055
Practice Address - Country:US
Practice Address - Phone:928-251-2541
Practice Address - Fax:833-450-5183
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12761208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ542416Medicaid
AZZ76163Medicare PIN