Provider Demographics
NPI:1235110719
Name:LEIDLEIN, JANE H (MD)
Entity Type:Individual
Prefix:DR
First Name:JANE
Middle Name:H
Last Name:LEIDLEIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 CIRCLE WAY ST
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5233
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:117 CIRCLE WAY ST
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5233
Practice Address - Country:US
Practice Address - Phone:979-297-4042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4298207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX10017638OtherAMERIGROUP
TX180036211OtherRAILROAD MEDICARE
TX096931301Medicaid
TX8S4250OtherBCBS
TX096931303Medicaid
TXG39351Medicare UPIN
TX8S4250OtherBCBS