Healthcare Provider Details

I. General information

NPI: 1588620447
Provider Name (Legal Business Name): WILLIAM A. LEESON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 03/19/2022
Certification Date: 03/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

454 ST MICHAELS DR
SANTA FE NM
87505-7602
US

IV. Provider business mailing address

PO BOX 26666 PROVIDER ENROLLMENT
ALBUQEURQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-303-5000
  • Fax:
Mailing address:
  • Phone: 505-923-6770
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2005-0499
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: