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General NPI Number Information
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NPI Number | 1043490188
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Entity Type | Organization
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Legal Business Name | LIESEL E.A. LEEDY MD PA
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Dates
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Enumeration Date | 11/06/2007
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Last Update Date | 11/11/2010
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Provider Practice Location Address
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Address Line | 1204 N MOUND ST
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City | NACOGDOCHES
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State | TX
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Zip | 75961-4027
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Country | US
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Telephone | 936-564-4611
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 635151
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City | NACOGDOCHES
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State | TX
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Zip | 75963-5151
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Country | US
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Telephone | 936-462-7844
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Fax | 936-462-7855
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Authorized Official
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Title or Position | PRESIDENT
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Name | LIESEL E.A. LEEDY
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Credential | MD
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Telephone | 936-462-7844
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | J4308
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License Number State | TX
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