Healthcare Provider Details

I. General information

NPI: 1639829088
Provider Name (Legal Business Name): PETER THOMAS LEISTIKOW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2022
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MANNING DR
CHAPEL HILL NC
27514-4226
US

IV. Provider business mailing address

101 MANNING DR
CHAPEL HILL NC
27514-4226
US

V. Phone/Fax

Practice location:
  • Phone: 984-974-1000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number2026-03789
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: