Provider Demographics
NPI:1023493822
Name:LEATHERBURY, ROBERT (CCP)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:LEATHERBURY
Suffix:
Gender:M
Credentials:CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:514 FLORA SPRINGS CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-6688
Mailing Address - Country:US
Mailing Address - Phone:213-308-7759
Mailing Address - Fax:
Practice Address - Street 1:514 FLORA SPRINGS CT
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-6688
Practice Address - Country:US
Practice Address - Phone:213-308-7759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-22
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist