Provider Demographics
NPI:1215937446
Name:LEESAR, MASSOUD
Entity type:Individual
Prefix:
First Name:MASSOUD
Middle Name:
Last Name:LEESAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 6TH AVE S
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35233-2110
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2000 6TH AVE S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-2110
Practice Address - Country:US
Practice Address - Phone:205-934-9999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL31656207RI0011X, 207RI0011X
OH35087511207R00000X, 207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02408599Medicaid
OH2777660Medicaid
KY64292063Medicaid
IN200058830Medicaid
P01133678OtherRAILROAD/TRAVELERS
AL51125866OtherBCBS
AL138239Medicaid
IN200058830Medicaid
P01133678OtherRAILROAD/TRAVELERS
102I060322Medicare PIN
KY64292063Medicaid