Basic Information
| Provider Information | |||||||||
| NPI: | 1104113190 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEYZOREK HARE | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | D. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARE | ||||||||
| OtherFirstName: | JULIE | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 150 DUNCAN ROAD | ||||||||
| Address2: | |||||||||
| City: | BUCKEYE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249249037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047997400 | ||||||||
| FaxNumber: | 3047992276 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 DUNCAN ROAD | ||||||||
| Address2: | |||||||||
| City: | BUCKEYE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249249037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047997400 | ||||||||
| FaxNumber: | 3047992276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2011 | ||||||||
| LastUpdateDate: | 01/02/2015 | ||||||||
| 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 | 207QA0401X | 25895 | WV | Y | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
ID Information
| ID | Type | State | Issuer | Description | 207Q00000X | 01 | VA | FAMILY MEDICINE | OTHER |