Provider Demographics
NPI:1043379944
Name:LEACH, DAVID BRYAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BRYAN
Last Name:LEACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W A ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-6000
Mailing Address - Country:US
Mailing Address - Phone:208-882-4662
Mailing Address - Fax:208-883-6557
Practice Address - Street 1:2500 W A ST
Practice Address - Street 2:SUITE 202
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-6000
Practice Address - Country:US
Practice Address - Phone:208-882-4662
Practice Address - Fax:208-883-6557
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8044207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805779000Medicaid
ID1143511Medicare ID - Type Unspecified
ID805779000Medicaid