Provider Demographics
NPI:1427052851
Name:LEYENSON, VADIM (MD)
Entity type:Individual
Prefix:DR
First Name:VADIM
Middle Name:
Last Name:LEYENSON
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 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:707-525-2902
Mailing Address - Fax:707-525-2904
Practice Address - Street 1:95 MONTGOMERY DR STE 104
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-6617
Practice Address - Country:US
Practice Address - Phone:707-525-2902
Practice Address - Fax:707-525-2904
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMC-1352207RC0200X
CA522342207RC0200X, 207RP1001X
ORMD184074207RP1001X, 207RC0200X
CA1107207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC154059OtherSTATE MEDICAL LICENSE
IL36093324Medicaid
ILL78876Medicare ID - Type Unspecified