Provider Demographics
NPI:1205863321
Name:MATTHEWS, LELAND R (MD)
Entity Type:Individual
Prefix:
First Name:LELAND
Middle Name:R
Last Name:MATTHEWS
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 1:421 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2403
Mailing Address - Country:US
Mailing Address - Phone:812-336-0168
Mailing Address - Fax:812-335-7372
Practice Address - Street 1:421 W 1ST ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2403
Practice Address - Country:US
Practice Address - Phone:812-336-0168
Practice Address - Fax:812-335-7372
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01021207207VG0400X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
INE03779Medicare UPIN
IN252770AAMedicare PIN