Provider Demographics
NPI:1083693493
Name:LEEDHAM, STEWART JOHN (DPM)
Entity Type:Individual
Prefix:
First Name:STEWART
Middle Name:JOHN
Last Name:LEEDHAM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 N HENDERSON ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-2575
Mailing Address - Country:US
Mailing Address - Phone:309-343-7665
Mailing Address - Fax:309-343-3567
Practice Address - Street 1:1134 N HENDERSON ST
Practice Address - Street 2:SUITE F
Practice Address - City:GALESBURG
Practice Address - State:IL
Practice Address - Zip Code:61401-2575
Practice Address - Country:US
Practice Address - Phone:309-343-7665
Practice Address - Fax:309-343-3567
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU11703Medicare UPIN
IL941920Medicare ID - Type Unspecified