=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902051840
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD ROYAL LEITZEN DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/19/2008
-----------------------------------------------------
Last Update Date | 06/28/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 705 WARRENVILLE RD SUITE B
-----------------------------------------------------
City | WHEATON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60189-6379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-668-8277
-----------------------------------------------------
Fax | 630-668-3358
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 527 IRVINGTON CT
-----------------------------------------------------
City | BARTLETT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60103-4653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-843-7167
-----------------------------------------------------
Fax | 630-668-3358
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 016.005466
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------