Healthcare Provider Details

I. General information

NPI: 1306830922
Provider Name (Legal Business Name): BRENT LEEDLE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 01/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 N 3RD AVE STE 201
SANDPOINT ID
83864-1689
US

IV. Provider business mailing address

606 N 3RD AVE STE 201
SANDPOINT ID
83864-1689
US

V. Phone/Fax

Practice location:
  • Phone: 208-263-8597
  • Fax: 208-265-0667
Mailing address:
  • Phone: 208-263-8597
  • Fax: 208-265-0667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number8474
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberM-10527
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: