Provider Demographics
NPI:1811945249
Name:LEEPER, TOMMY C (MD)
Entity type:Individual
Prefix:
First Name:TOMMY
Middle Name:C
Last Name:LEEPER
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:PO BOX 52890
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85208-0145
Mailing Address - Country:US
Mailing Address - Phone:480-357-8411
Mailing Address - Fax:480-357-8532
Practice Address - Street 1:2080 W SOUTHERN AVE
Practice Address - Street 2:A-2
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85220-7455
Practice Address - Country:US
Practice Address - Phone:480-357-8411
Practice Address - Fax:480-357-8532
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33752207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ109753Medicare UPIN
AZI53003Medicare PIN