Provider Demographics
NPI:1013918184
Name:LEITHAUSER, LANCE G (MD)
Entity type:Individual
Prefix:DR
First Name:LANCE
Middle Name:G
Last Name:LEITHAUSER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:9715 MEDICAL CENTER DR
Mailing Address - Street 2:535
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3320
Mailing Address - Country:US
Mailing Address - Phone:301-294-9400
Mailing Address - Fax:301-294-0149
Practice Address - Street 1:9715 MEDICAL CENTER DR
Practice Address - Street 2:535
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3320
Practice Address - Country:US
Practice Address - Phone:301-294-9400
Practice Address - Fax:301-294-0149
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2011-03-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDD0021581208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD189061100Medicaid
MD0819656OtherAETNA
MD9440-0001OtherCF BC/BS NCA
MD20071OtherMAMSI
MD05008OtherAMERIGROUP
MD41680702OtherCF BC/BS MD
MD9440-0001OtherCF BC/BS NCA
MD41680702OtherCF BC/BS MD