Provider Demographics
NPI:1912056995
Name:LEAZZO, ANTHONY S (DO)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:S
Last Name:LEAZZO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 FARGO BLVD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-3591
Mailing Address - Country:US
Mailing Address - Phone:360-232-2200
Mailing Address - Fax:
Practice Address - Street 1:2425 FARGO BLVD
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-3591
Practice Address - Country:US
Practice Address - Phone:630-232-2200
Practice Address - Fax:630-232-1940
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036111542207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036111542Medicaid
ILP00433169OtherRAILROAD MEDICARE PTAN
IL036111542Medicaid