Healthcare Provider Details

I. General information

NPI: 1871518969
Provider Name (Legal Business Name): GARY JAMES LECLAIR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 08/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 MARTIN LUTHER KING JR PKWY
SPRINGFIELD OR
97477-7514
US

IV. Provider business mailing address

PO BOX 70368
SPRINGFIELD OR
97475-0120
US

V. Phone/Fax

Practice location:
  • Phone: 541-485-2777
  • Fax: 541-246-2353
Mailing address:
  • Phone: 541-485-2777
  • Fax: 541-246-2353

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLF00001937
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberMD09743
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: