Provider Demographics
NPI:1629012315
Name:AZAR, LEESA M (MD)
Entity type:Individual
Prefix:
First Name:LEESA
Middle Name:M
Last Name:AZAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4035 MERCANTILE DR
Mailing Address - Street 2:STE 101
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-2546
Mailing Address - Country:US
Mailing Address - Phone:503-697-3001
Mailing Address - Fax:503-697-0906
Practice Address - Street 1:9450 SW BARNES RD STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6642
Practice Address - Country:US
Practice Address - Phone:503-292-9560
Practice Address - Fax:503-292-9510
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD18772207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR066212Medicaid
ORF91292Medicare UPIN
OR119387Medicare ID - Type Unspecified