Provider Demographics
NPI:1932163532
Name:LEPORT, PETER CARY (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:CARY
Last Name:LEPORT
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 1:18111 BROOKHURST ST
Mailing Address - Street 2:SUITE 5600
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-6728
Mailing Address - Country:US
Mailing Address - Phone:714-861-4666
Mailing Address - Fax:714-916-5534
Practice Address - Street 1:18111 BROOKHURST ST
Practice Address - Street 2:SUITE 5600
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-6728
Practice Address - Country:US
Practice Address - Phone:714-861-4666
Practice Address - Fax:714-916-5534
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG47193174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G471930Medicaid
CA00G471930Medicaid
CAWG47193BMedicare PIN