Provider Demographics
NPI:1063862977
Name:LEISHMAN, BENJAMIN (DO)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:LEISHMAN
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 1:820 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-4714
Mailing Address - Country:US
Mailing Address - Phone:307-632-2434
Mailing Address - Fax:
Practice Address - Street 1:820 E 17TH ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4714
Practice Address - Country:US
Practice Address - Phone:307-632-2434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-21
Last Update Date:2017-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY101-T1207Q00000X
390200000X
WY101-T2207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program