Healthcare Provider Details

I. General information

NPI: 1932183498
Provider Name (Legal Business Name): PAUL C LEIDHEISER JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 04/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 RIVERSIDE DR
COLUMBUS OH
43212-1855
US

IV. Provider business mailing address

1800 RIVERSIDE DR
COLUMBUS OH
43212-1855
US

V. Phone/Fax

Practice location:
  • Phone: 614-486-9511
  • Fax: 614-487-3156
Mailing address:
  • Phone: 614-486-9511
  • Fax: 614-487-3156

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35-03-9780
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: