Provider Demographics
NPI:1124179767
Name:LEAKE, LAWRENCE A (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:A
Last Name:LEAKE
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 1:2101 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-5340
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2809 DENNY AVE
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581-5301
Practice Address - Country:US
Practice Address - Phone:228-809-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSMS13594207P00000X
MS13594207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009926475Medicaid
646000515OtherTRICARE
MS00112590Medicaid
646000515OtherBLUE CROSS OF MS
930026898OtherRAILROAD MEDICARE