Provider Demographics
NPI:1083661250
Name:HOLGERSEN, LEIF ODD (MD)
Entity type:Individual
Prefix:
First Name:LEIF
Middle Name:ODD
Last Name:HOLGERSEN
Suffix:
Gender:M
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:PO BOX 667
Mailing Address - Street 2:
Mailing Address - City:PURCHASE
Mailing Address - State:NY
Mailing Address - Zip Code:10577-0667
Mailing Address - Country:US
Mailing Address - Phone:914-337-2455
Mailing Address - Fax:914-380-6713
Practice Address - Street 1:141 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:HARTSDALE
Practice Address - State:NY
Practice Address - Zip Code:10530-2319
Practice Address - Country:US
Practice Address - Phone:914-337-2455
Practice Address - Fax:914-380-6713
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0979832086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00166087Medicaid
NY644511Medicare ID - Type Unspecified
NY00166087Medicaid