Provider Demographics
NPI:1336125004
Name:LEDING, MARK J (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:LEDING
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 DEXTER CT
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3461
Mailing Address - Country:US
Mailing Address - Phone:563-344-6667
Mailing Address - Fax:563-344-6740
Practice Address - Street 1:1410 N. STREET
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732
Practice Address - Country:US
Practice Address - Phone:563-244-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036074323207L00000X
IA2398207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036074323Medicaid
IL036074323Medicaid
IAL11560Medicare PIN