MEDICARE: CHARLES RAYMOND LEACH MD

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	F4922	TX

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	283520YL7A	OTHER	TX	MEDICARE - OTHER COUNTY
5	110094182	OTHER	TX	RAILROAD MEDICARE

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1205879855
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES RAYMOND LEACH MD

Provider Business Mailing Address
First Line	:	4440 E HIGHWAY 287
Second Line	:
City	:	MIDLOTHIAN
State	:	TX
Zip	:	76065-5576
Country	:	US
Telephone Number	:	972-723-5590
Fax Number	:	972-723-5592

Provider Business Practice Location Address
First Line	:	4440 E HIGHWAY 287
Second Line	:
City	:	MIDLOTHIAN
State	:	TX
Zip	:	76065-5576
Country	:	US
Telephone Number	:	972-723-5590
Fax Number	:	972-723-5592

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2006
Last Update Date	:	09/05/2014

4440 E MAIN ST
MIDLOTHIAN, TX
76065-5576

Practice Phone: 469-257-1401
Practice Fax:

4430 E HIGHWAY 287 STE 100
MIDLOTHIAN, TX
76065-5576