Healthcare Provider Details

I. General information

NPI: 1740283423
Provider Name (Legal Business Name): PETER LEOPOLD D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2580 HIGHWAY 95 STE 224
BULLHEAD CITY AZ
86442-7332
US

IV. Provider business mailing address

3333 E CAMELBACK RD SUITE 180
PHOENIX AZ
85018-2322
US

V. Phone/Fax

Practice location:
  • Phone: 928-704-7011
  • Fax: 928-704-7014
Mailing address:
  • Phone: 602-997-0484
  • Fax: 602-224-3358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number3500
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: