Healthcare Provider Details

I. General information

NPI: 1407805484
Provider Name (Legal Business Name): JOHNETTE K LEIKAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JOHNETTE LEIKAM PETERSON

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 E STANLEY BLVD #103
LIVERMORE CA
94550-4200
US

IV. Provider business mailing address

1133 E STANLEY BLVD #103
LIVERMORE CA
94550-4200
US

V. Phone/Fax

Practice location:
  • Phone: 925-455-5050
  • Fax: 925-667-2122
Mailing address:
  • Phone: 925-455-5050
  • Fax: 925-667-2122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC41599
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: