MEDICARE: MARK G. LEIFESTE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	23486	CO

General Provider Information

NPI Number	:	1033156427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK G. LEIFESTE M.D.

Provider Business Mailing Address
First Line	:	PO BOX 2086
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80522-2086
Country	:	US
Telephone Number	:	303-444-3443
Fax Number	:	970-221-3730

Provider Business Practice Location Address
First Line	:	4770 BASELINE RD
Second Line	:	SUITE #300
City	:	BOULDER
State	:	CO
Zip	:	80303-2666
Country	:	US
Telephone Number	:	303-449-6577
Fax Number	:	303-447-1880

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	07/08/2007

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