Healthcare Provider Details

I. General information

NPI: 1902875347
Provider Name (Legal Business Name): FREDERIC STUART LEEDS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 12/31/2025
Certification Date: 12/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3033 KETTERING BLVD STE 100
MORAINE OH
45439-1948
US

IV. Provider business mailing address

PO BOX 40412
BELFAST ME
04915-1255
US

V. Phone/Fax

Practice location:
  • Phone: 937-293-2133
  • Fax:
Mailing address:
  • Phone: 330-896-5651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35075225
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number35075225
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: