MEDICARE: ERICA DRYDEN LEAZENBY MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	01054903A	IN

General Provider Information

NPI Number	:	1093708380
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERICA DRYDEN LEAZENBY MD

Provider Business Mailing Address
First Line	:	10330 N MERIDIAN ST
Second Line	:	SUITE 201
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46290-1024
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	13250 HAZEL DELL PKWY
Second Line	:	SUITE 104
City	:	CARMEL
State	:	IN
Zip	:	46033-8521
Country	:	US
Telephone Number	:	317-415-6900
Fax Number	:	317-415-6910

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2005
Last Update Date	:	10/19/2007

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