Provider Demographics
NPI:1407928112
Name:LEEDY, DANIEL ALLAN (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:ALLAN
Last Name:LEEDY
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 1:541 NE 20TH AVE STE 225
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2895
Mailing Address - Country:US
Mailing Address - Phone:503-963-2801
Mailing Address - Fax:503-963-2825
Practice Address - Street 1:1508 DIVISION ST
Practice Address - Street 2:SUITE 115
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1582
Practice Address - Country:US
Practice Address - Phone:503-656-0601
Practice Address - Fax:503-656-1389
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17211174400000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2038807Medicaid
OR084509Medicaid
ORG05472Medicare UPIN
OR175991Medicare PIN
OR084509Medicaid
WA2038807Medicaid