Provider Demographics
NPI:1275605586
Name:LEISY, JERALD W (MD PA)
Entity Type:Individual
Prefix:MR
First Name:JERALD
Middle Name:W
Last Name:LEISY
Suffix:
Gender:M
Credentials:MD PA
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3310 EAST DOUGLAS AVE # 101
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208
Mailing Address - Country:US
Mailing Address - Phone:316-681-2937
Mailing Address - Fax:316-681-1262
Practice Address - Street 1:3310 EAST DOUGLAS AVE #101
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208
Practice Address - Country:US
Practice Address - Phone:316-681-2937
Practice Address - Fax:316-681-1262
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS145742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100164140AMedicaid
KS100164140AMedicaid
000130Medicare ID - Type Unspecified