Provider Demographics
NPI:1033742283
Name:DR. JOHN C. LEATHERMAN PLLC
Entity Type:Organization
Organization Name:DR. JOHN C. LEATHERMAN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:LEATHERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-876-2238
Mailing Address - Street 1:PO BOX 420
Mailing Address - Street 2:
Mailing Address - City:RAMONA
Mailing Address - State:OK
Mailing Address - Zip Code:74061-0420
Mailing Address - Country:US
Mailing Address - Phone:918-536-1024
Mailing Address - Fax:918-536-4003
Practice Address - Street 1:400 WYANDOTTE PL
Practice Address - Street 2:
Practice Address - City:RAMONA
Practice Address - State:OK
Practice Address - Zip Code:74061-3678
Practice Address - Country:US
Practice Address - Phone:918-536-1024
Practice Address - Fax:918-536-4003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty