Healthcare Provider Details

I. General information

NPI: 1942563465
Provider Name (Legal Business Name): JEFFREY R LESUEUR MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 06/19/2012
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: HEATHER SCOTT
Title or Position: OFFICE MANAGER
Credential:
Phone: 928-532-0072