Basic Information
| Provider Information | |||||||||
| NPI: | 1336179886 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REBER | ||||||||
| FirstName: | LEON | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 754 S MAIN ST | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | ST GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847705504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356282671 | ||||||||
| FaxNumber: | 4356341601 | ||||||||
| Practice Location | |||||||||
| Address1: | 754 SOUTH MAIN | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | ST GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356282671 | ||||||||
| FaxNumber: | 4356341601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 01/13/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 60912731501 | UT | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213E00000X | 506 | NV | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0103X | 506 | NV | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | 6091273-0501 | UT | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 100509597 | 05 | NV | MEDICAID |