Provider Demographics
NPI:1942563465
Name:JEFFREY R LESUEUR MD PC
Entity type:Organization
Organization Name:JEFFREY R LESUEUR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-532-0072
Mailing Address - Street 1:5448 HIGHWAY 260
Mailing Address - Street 2:SUITE 140
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-5739
Mailing Address - Country:US
Mailing Address - Phone:928-532-0072
Mailing Address - Fax:928-532-0078
Practice Address - Street 1:5448 HIGHWAY 260
Practice Address - Street 2:SUITE 140
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-5739
Practice Address - Country:US
Practice Address - Phone:928-532-0072
Practice Address - Fax:928-532-0078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ45950207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ699587Medicaid