Provider Demographics
NPI:1003889866
Name:LEIDNER, CHARLES J (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:LEIDNER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:12 PHILLIPS BEACH AVENUE
Mailing Address - Street 2:
Mailing Address - City:SWAMPSCOTT
Mailing Address - State:MA
Mailing Address - Zip Code:01907
Mailing Address - Country:US
Mailing Address - Phone:781-599-1915
Mailing Address - Fax:
Practice Address - Street 1:55 HIGHLAND AVUENE
Practice Address - Street 2:SUITE 201
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970
Practice Address - Country:US
Practice Address - Phone:978-745-6601
Practice Address - Fax:978-744-4872
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA41165207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0012295OtherNEIGHBORHOOD HEALTH
MA041165OtherTUFTS
MAD25068OtherBLUE SHIELD
MA19337OtherHARVARD PILGRIM
MA1000022OtherUNITED HEALTH CARE
MA2084278OtherAETNA
MA2054434Medicaid
MA36228OtherFALLON
MA2054434Medicaid
MA36228OtherFALLON