Provider Demographics
NPI:1073620142
Name:LEACH, CHARLES THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:THOMAS
Last Name:LEACH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 N. SAN SABA, STE.1003
Mailing Address - Street 2:CHILDREN'S HOSPITAL OF SAN ANTONIO
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207
Mailing Address - Country:US
Mailing Address - Phone:210-704-3391
Mailing Address - Fax:
Practice Address - Street 1:333 N SANTA ROSA ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-3108
Practice Address - Country:US
Practice Address - Phone:210-704-3391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH68822080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX103034801Medicaid