Healthcare Provider Details

I. General information

NPI: 1740268408
Provider Name (Legal Business Name): MARK C LEESON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 01/25/2022
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 MORRIS RD SUITE 2
SHELBY OH
44875-1170
US

IV. Provider business mailing address

PO BOX 7527
DUBLIN OH
43017-0727
US

V. Phone/Fax

Practice location:
  • Phone: 419-347-4177
  • Fax:
Mailing address:
  • Phone: 614-544-6356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number042998
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: