Healthcare Provider Details

I. General information

NPI: 1588073290
Provider Name (Legal Business Name): MICHELLE ELIZABETH LEONARD DEITHLOFF D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MICHELLE ELIZABETH LEONARD DPM

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 BRUNN SCHOOL RD
SANTA FE NM
87505-1102
US

IV. Provider business mailing address

PO BOX 540610
N SALT LAKE UT
84054-0610
US

V. Phone/Fax

Practice location:
  • Phone: 505-395-9575
  • Fax: 877-540-1253
Mailing address:
  • Phone: 801-505-0821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD401
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: