Provider Demographics
NPI:1194765859
Name:ETTINGER, LEIGH MARK (MD, MS)
Entity type:Individual
Prefix:DR
First Name:LEIGH
Middle Name:MARK
Last Name:ETTINGER
Suffix:
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 MANCHESTER RD STE 105
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-2895
Mailing Address - Country:US
Mailing Address - Phone:458-452-1700
Mailing Address - Fax:
Practice Address - Street 1:301 MANCHESTER RD STE 105
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-2895
Practice Address - Country:US
Practice Address - Phone:845-452-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA077612002080P0210X
NY221725-01208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0210XAllopathic & Osteopathic PhysiciansPediatricsPediatric Nephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJI17480Medicare UPIN