Healthcare Provider Details

I. General information

NPI: 1356364624
Provider Name (Legal Business Name): BENJAMIN WALLACE LESUEUR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 04/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11130 N TATUM BLVD #100
PHOENIX AZ
85028
US

IV. Provider business mailing address

11130 N TATUM BLVD #100
PHOENIX AZ
85028
US

V. Phone/Fax

Practice location:
  • Phone: 602-494-1817
  • Fax: 602-494-7103
Mailing address:
  • Phone: 602-494-1817
  • Fax: 602-494-7107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number29865
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: