Provider Demographics
NPI:1043490188
Name:LIESEL E.A. LEEDY MD PA
Entity Type:Organization
Organization Name:LIESEL E.A. LEEDY MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LIESEL
Authorized Official - Middle Name:EA
Authorized Official - Last Name:LEEDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-462-7844
Mailing Address - Street 1:PO BOX 635151
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75963-5151
Mailing Address - Country:US
Mailing Address - Phone:936-462-7844
Mailing Address - Fax:936-462-7855
Practice Address - Street 1:1204 N MOUND ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-4027
Practice Address - Country:US
Practice Address - Phone:936-564-4611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4308207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179619501Medicaid
TX0052NAOtherBLUE CROSS BLUE SHIELD
TX00890ZMedicare PIN
TX179619501Medicaid
DF1054Medicare PIN