=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871542050
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FREDRICK SEBASTIAN LEACH MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2006
-----------------------------------------------------
Last Update Date | 04/10/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7000 W PLANO PKWY STE 240
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-1637
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-384-3470
-----------------------------------------------------
Fax | 972-384-3474
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 117285
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75011-7285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-384-3470
-----------------------------------------------------
Fax | 972-384-3474
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208800000X
-----------------------------------------------------
Taxonomy Name | Urology Physician
-----------------------------------------------------
License Number | J9736
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------