Healthcare Provider Details

I. General information

NPI: 1043217839
Provider Name (Legal Business Name): SUE A LEATHERMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 10/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2365 INNIS RD
COLUMBUS OH
43224
US

IV. Provider business mailing address

882 S HAMILTON RD
COLUMBUS OH
43213
US

V. Phone/Fax

Practice location:
  • Phone: 614-416-4325
  • Fax: 614-416-4320
Mailing address:
  • Phone: 614-235-5555
  • Fax: 614-338-6805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35044589L
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.044589
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: