Provider Demographics
NPI:1235135815
Name:GILMORE, LELAND T (DPM)
Entity Type:Individual
Prefix:
First Name:LELAND
Middle Name:T
Last Name:GILMORE
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 1:8101 HINSON FARM RD STE 301
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22306-3405
Mailing Address - Country:US
Mailing Address - Phone:703-560-3773
Mailing Address - Fax:703-799-0050
Practice Address - Street 1:8101 HINSON FARM RD STE 301
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-3405
Practice Address - Country:US
Practice Address - Phone:703-560-3773
Practice Address - Fax:703-799-0050
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000826213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA290062OtherANTHEM
VA009302867Medicaid
VA480008618OtherRAILROAD MEDICRE
VAA729 0001OtherCAREFIRST/BCBS
DC010837200Medicaid
VA1699963157OtherGROUP NPI
VA105546001OtherDME SUPPLIER
VA480008618OtherRAILROAD MEDICRE
VA009302867Medicaid