Healthcare Provider Details

I. General information

NPI: 1508810185
Provider Name (Legal Business Name): LAURA L. LEISTIKO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2975 SYCAMORE DR EMERGENCY DEPARTMENT
SIMI VALLEY CA
93065-1201
US

IV. Provider business mailing address

PO BOX 662154
ARCADIA CA
91066-2154
US

V. Phone/Fax

Practice location:
  • Phone: 805-955-6000
  • Fax:
Mailing address:
  • Phone: 626-447-0296
  • Fax: 626-447-6057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA90865
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: