Provider Demographics
NPI:1235399627
Name:LEAF, JEDIDIAH C (MD)
Entity Type:Individual
Prefix:DR
First Name:JEDIDIAH
Middle Name:C
Last Name:LEAF
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 1:4121 GLENBROOK DR
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-3665
Mailing Address - Country:US
Mailing Address - Phone:337-296-9666
Mailing Address - Fax:
Practice Address - Street 1:12221 MERIT DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-2202
Practice Address - Country:US
Practice Address - Phone:214-217-1914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-10
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP3643207P00000X
LAMD203840207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX303479501Medicaid
TXP01075810OtherRAILROAD
TX303479502Medicaid
TXTXB160518Medicare PIN
TXTXB160517Medicare PIN