Healthcare Provider Details

I. General information

NPI: 1912056995
Provider Name (Legal Business Name): ANTHONY S LEAZZO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 12/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2425 FARGO BLVD
GENEVA IL
60134-3591
US

IV. Provider business mailing address

2425 FARGO BLVD
GENEVA IL
60134-3591
US

V. Phone/Fax

Practice location:
  • Phone: 630-232-2200
  • Fax: 630-232-1940
Mailing address:
  • Phone: 360-232-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036111542
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036111542
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: