=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942563465
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JEFFREY R LESUEUR MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2012
-----------------------------------------------------
Last Update Date | 06/19/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5448 HIGHWAY 260 SUITE 140
-----------------------------------------------------
City | LAKESIDE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85929-5739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-532-0072
-----------------------------------------------------
Fax | 928-532-0078
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5448 HIGHWAY 260 SUITE 140
-----------------------------------------------------
City | LAKESIDE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85929-5739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-532-0072
-----------------------------------------------------
Fax | 928-532-0078
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | HEATHER SCOTT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 928-532-0072
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 45950
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------