Provider Demographics
NPI:1255475570
Name:LEARY, FREDRIC DONALD JR (MD)
Entity Type:Individual
Prefix:
First Name:FREDRIC
Middle Name:DONALD
Last Name:LEARY
Suffix:JR
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 1:1135 S GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60304-1908
Mailing Address - Country:US
Mailing Address - Phone:708-524-5079
Mailing Address - Fax:303-466-5949
Practice Address - Street 1:1135 S GROVE AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60304-1908
Practice Address - Country:US
Practice Address - Phone:708-524-5079
Practice Address - Fax:303-466-5949
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F82400Medicare UPIN