Provider Demographics
NPI:1740466549
Name:LEITNER, JEFFREY DALE (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:DALE
Last Name:LEITNER
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 1:11209 N TATUM BLVD STE 175
Mailing Address - Street 2:STONECREEK MEDICAL ASSOCIATES
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-6016
Mailing Address - Country:US
Mailing Address - Phone:602-652-8900
Mailing Address - Fax:602-652-8909
Practice Address - Street 1:11209 N TATUM BLVD STE 175
Practice Address - Street 2:STONECREEK MEDICAL ASSOCIATES
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-6016
Practice Address - Country:US
Practice Address - Phone:602-652-8900
Practice Address - Fax:602-652-8909
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-11
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ81048207K00000X
AZ42839207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ81048OtherTRAINING PERMIT
AZ1740466549Medicare UPIN