Healthcare Provider Details

I. General information

NPI: 1629323746
Provider Name (Legal Business Name): CALLIE LEEANNE RZASA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2012
Last Update Date: 12/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 LEADER AVE RM 252
LEXINGTON KY
40506-3215
US

IV. Provider business mailing address

138 LEADER AVE RM 252
LEXINGTON KY
40506-3215
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-5962
  • Fax:
Mailing address:
  • Phone: 859-323-5962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberTP234
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberA118429
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberA118429
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number49619
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: