Provider Demographics
NPI:1043248867
Name:LEAK, BENJAMIN J (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:J
Last Name:LEAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 EASTLAND DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3514
Mailing Address - Country:US
Mailing Address - Phone:309-663-9424
Mailing Address - Fax:309-663-6350
Practice Address - Street 1:1401 EASTLAND DR
Practice Address - Street 2:SUITE B
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3514
Practice Address - Country:US
Practice Address - Phone:309-663-9424
Practice Address - Fax:309-663-6350
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5732045OtherBC BS PROVIDER NUMBER
IL0723870001OtherDME PROVIDER NUMBER
ILP00100008OtherRAILROAD MEDICARE
IL798270Medicare ID - Type Unspecified
K04769Medicare PIN
ILI02495Medicare UPIN