Provider Demographics
NPI:1740250935
Name:PETRICH, LESLEY A (MD)
Entity type:Individual
Prefix:
First Name:LESLEY
Middle Name:A
Last Name:PETRICH
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 1:1920 E BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-1511
Mailing Address - Country:US
Mailing Address - Phone:480-345-5000
Mailing Address - Fax:
Practice Address - Street 1:1920 E BASELINE RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-1511
Practice Address - Country:US
Practice Address - Phone:480-345-5000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ168912085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ172213Medicaid
AZ63557Medicare ID - Type Unspecified
AZ63560Medicare ID - Type Unspecified
AZ26110Medicare ID - Type Unspecified
AZ63562Medicare ID - Type Unspecified
AZWCKHL136Medicare ID - Type Unspecified
AZ63563Medicare ID - Type Unspecified
AZ21831Medicare ID - Type Unspecified
AZD38814Medicare UPIN
AZ63555Medicare ID - Type Unspecified
AZ63559Medicare ID - Type Unspecified
AZ63561Medicare ID - Type Unspecified
AZ172213Medicaid
AZ63556Medicare ID - Type Unspecified
AZ63558Medicare ID - Type Unspecified