Healthcare Provider Details

I. General information

NPI: 1104814425
Provider Name (Legal Business Name): MONTE JOHN LEIDENIX M.D. F.A.C.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 01/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 N 9TH ST
BISMARCK ND
58501-4112
US

IV. Provider business mailing address

620 N 9TH ST
BISMARCK ND
58501-4112
US

V. Phone/Fax

Practice location:
  • Phone: 701-255-4673
  • Fax: 701-255-4934
Mailing address:
  • Phone: 701-255-4673
  • Fax: 701-255-4934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number7678
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: