Healthcare Provider Details

I. General information

NPI: 1407825540
Provider Name (Legal Business Name): STEPHEN WESLEY LEECH D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 08/20/2021
Certification Date: 08/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4776 EAGLERIDGE CIR
PUEBLO CO
81008-2189
US

IV. Provider business mailing address

318 S MCCULLOCH LN
PUEBLO WEST CO
81007-4041
US

V. Phone/Fax

Practice location:
  • Phone: 719-553-1000
  • Fax:
Mailing address:
  • Phone: 719-251-5779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number427
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: