=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427086636
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES C LEAK M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2006
-----------------------------------------------------
Last Update Date | 01/19/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 434 N CAPTAIN GLOSTER DR
-----------------------------------------------------
City | GLOSTER
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39638-3401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-225-4711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 639
-----------------------------------------------------
City | CENTREVILLE
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39631-0639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 601-645-5221
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 12264
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------