Healthcare Provider Details

I. General information

NPI: 1003818642
Provider Name (Legal Business Name): KATHLEEN DOLORES VAN LEEUWEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHLEEN DOLORES GRAZIANO MD

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 03/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 E THOMAS RD
PHOENIX AZ
85016-7710
US

IV. Provider business mailing address

3200 E CAMELBACK RD STE 250
PHOENIX AZ
85018-2327
US

V. Phone/Fax

Practice location:
  • Phone: 602-933-0016
  • Fax: 602-933-4309
Mailing address:
  • Phone: 602-933-1814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number34139
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: