Healthcare Provider Details

I. General information

NPI: 1336366335
Provider Name (Legal Business Name): JEFFREY RAYNE LESUEUR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 01/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5448 HIGHWAY 260 SUITE 140
LAKESIDE AZ
85929-5739
US

IV. Provider business mailing address

5448 HIGHWAY 260 SUITE 140
LAKESIDE AZ
85929-5739
US

V. Phone/Fax

Practice location:
  • Phone: 928-532-0072
  • Fax: 928-532-0078
Mailing address:
  • Phone: 928-532-0072
  • Fax: 928-532-0078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number45950
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: