Healthcare Provider Details

I. General information

NPI: 1649234915
Provider Name (Legal Business Name): MAI P LEOPOLD DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 08/19/2020
Certification Date: 08/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10151 SE SUNNYSIDE RD STE 100
CLACKAMAS OR
97015-5705
US

IV. Provider business mailing address

PO BOX 92900
PORTLAND OR
97292-0900
US

V. Phone/Fax

Practice location:
  • Phone: 503-659-0880
  • Fax: 503-513-7425
Mailing address:
  • Phone: 503-659-0880
  • Fax: 503-513-7425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO12247
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: