Healthcare Provider Details

I. General information

NPI: 1194936807
Provider Name (Legal Business Name): LEESA DAMAR MCCAULEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LEESA DAMAR HARTY MD

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 17TH ST
COLUMBUS IN
47201-5351
US

IV. Provider business mailing address

PO BOX 775383
CHICAGO IL
60677-5383
US

V. Phone/Fax

Practice location:
  • Phone: 812-376-5974
  • Fax: 812-375-3203
Mailing address:
  • Phone: 812-376-5315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number57-012612
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01074422A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number01074422A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: