Healthcare Provider Details

I. General information

NPI: 1043248867
Provider Name (Legal Business Name): BENJAMIN J LEAK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 09/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 EASTLAND DR SUITE B
BLOOMINGTON IL
61701-3514
US

IV. Provider business mailing address

1401 EASTLAND DR SUITE B
BLOOMINGTON IL
61701-3514
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-9424
  • Fax: 309-663-6350
Mailing address:
  • Phone: 309-663-9424
  • Fax: 309-663-6350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: