Provider Demographics
NPI:1407275811
Name:LEINER, CHARLES DEREK (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:DEREK
Last Name:LEINER
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 1:1250 E MARSHALL ST
Mailing Address - Street 2:BOX 980102
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23298-5051
Mailing Address - Country:US
Mailing Address - Phone:804-828-5323
Mailing Address - Fax:
Practice Address - Street 1:1250 E MARSHALL ST
Practice Address - Street 2:BOX 980509
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5051
Practice Address - Country:US
Practice Address - Phone:804-828-8786
Practice Address - Fax:804-828-5466
Is Sole Proprietor?:No
Enumeration Date:2014-04-14
Last Update Date:2017-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101261717207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program