Healthcare Provider Details

I. General information

NPI: 1740466549
Provider Name (Legal Business Name): JEFFREY DALE LEITNER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2008
Last Update Date: 07/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11209 N TATUM BLVD STE 175 STONECREEK MEDICAL ASSOCIATES
PHOENIX AZ
85028-6016
US

IV. Provider business mailing address

11209 N TATUM BLVD STE 175 STONECREEK MEDICAL ASSOCIATES
PHOENIX AZ
85028-6016
US

V. Phone/Fax

Practice location:
  • Phone: 602-652-8900
  • Fax: 602-652-8909
Mailing address:
  • Phone: 602-652-8900
  • Fax: 602-652-8909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number81048
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number42839
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: