Healthcare Provider Details

I. General information

NPI: 1265449169
Provider Name (Legal Business Name): BRUCE NORMAN LEISTIKOW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 02/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SHIELDS AVE
DAVIS CA
95616-5270
US

IV. Provider business mailing address

3410 MONTE VISTA AVE
DAVIS CA
95618-4931
US

V. Phone/Fax

Practice location:
  • Phone: 530-752-1011
  • Fax:
Mailing address:
  • Phone:
  • Fax: 530-752-3239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberG80992
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberG80992
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberG80992
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: