Provider Demographics
NPI:1063469914
Name:LEADERMAN, ERROL SCOTT (DO)
Entity Type:Individual
Prefix:
First Name:ERROL
Middle Name:SCOTT
Last Name:LEADERMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30237-0278
Mailing Address - Country:US
Mailing Address - Phone:770-968-9978
Mailing Address - Fax:770-968-9975
Practice Address - Street 1:6645 LAKE DR
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-2354
Practice Address - Country:US
Practice Address - Phone:770-968-9978
Practice Address - Fax:770-968-9975
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017844207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD30030Medicare UPIN
GA05BDKHHMedicare ID - Type Unspecified