Healthcare Provider Details

I. General information

NPI: 1720171507
Provider Name (Legal Business Name): ERIC JOHN LEUTE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 09/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

949 PALM AVENUE IMPERIAL BEACH HEALTH CENTER
IMPERIAL BEACH CA
91932
US

IV. Provider business mailing address

PO BOX 459 PO
IMPERIAL BEACH CA
91933-0459
US

V. Phone/Fax

Practice location:
  • Phone: 619-429-3733
  • Fax: 619-628-5550
Mailing address:
  • Phone: 619-429-3733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA80832
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: