Basic Information
Provider Information | |||||||||
NPI: | 1003818642 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VAN LEEUWEN | ||||||||
FirstName: | KATHLEEN | ||||||||
MiddleName: | DOLORES | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GRAZIANO | ||||||||
OtherFirstName: | KATHLEEN | ||||||||
OtherMiddleName: | DOLORES | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3200 E CAMELBACK RD STE 250 | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850182327 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6029331814 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1919 E THOMAS RD | ||||||||
Address2: |   | ||||||||
City: | PHOENIX | ||||||||
State: | AZ | ||||||||
PostalCode: | 850167710 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6029330016 | ||||||||
FaxNumber: | 6029334309 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/12/2005 | ||||||||
LastUpdateDate: | 03/29/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0120X | 34139 | AZ | Y |   | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery |
ID Information
ID | Type | State | Issuer | Description | 940610 | 05 | AZ |   | MEDICAID |