Healthcare Provider Details

I. General information

NPI: 1205875051
Provider Name (Legal Business Name): JOHN PAUL LELAND DO
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 LACEY ST
CAPE GIRARDEAU MO
63701-5230
US

IV. Provider business mailing address

2704 INDEPENDENCE ST APT 8
CAPE GIRARDEAU MO
63703-5014
US

V. Phone/Fax

Practice location:
  • Phone: 573-339-7699
  • Fax: 573-339-7644
Mailing address:
  • Phone: 573-339-7699
  • Fax: 573-339-7644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2004028646
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: