Healthcare Provider Details

I. General information

NPI: 1831578699
Provider Name (Legal Business Name): JAMES LEAKE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2015
Last Update Date: 05/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 VANN ST NE SUITE 150
MARIETTA GA
30060-7357
US

IV. Provider business mailing address

120 VANN ST NE SUITE 150
MARIETTA GA
30060-7357
US

V. Phone/Fax

Practice location:
  • Phone: 770-421-1242
  • Fax: 770-424-6652
Mailing address:
  • Phone: 770-421-1242
  • Fax: 770-424-6652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number026144
License Number StateGA

VIII. Authorized Official

Name: MR. JAMES E LEAKE
Title or Position: M.D.
Credential: M.D.
Phone: 770-421-1242