Healthcare Provider Details

I. General information

NPI: 1417184771
Provider Name (Legal Business Name): KATRINA MCCLANE LESHANSKI D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2009
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 CHURCH ST
VIDALIA GA
30474-4770
US

IV. Provider business mailing address

PO BOX 407
VIDALIA GA
30475-0407
US

V. Phone/Fax

Practice location:
  • Phone: 912-538-8484
  • Fax: 912-538-8665
Mailing address:
  • Phone: 912-535-5581
  • Fax: 912-535-5457

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0102202657
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS14200
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number081732
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberOS14200
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number081732
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: