Provider Demographics
NPI:1063494102
Name:JAMISON, LEAH BRYANT (MD)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:BRYANT
Last Name:JAMISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:D
Other - Last Name:BRYANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2401 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3428
Practice Address - Country:US
Practice Address - Phone:765-751-2649
Practice Address - Fax:765-281-6671
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01036948A207LP3000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric Anesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100118800Medicaid
IN224040194OtherMEDICARE PTAN
IN719600PPMedicare PIN