Provider Demographics
NPI:1417930967
Name:LEEDS, GARY JORDAN (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:JORDAN
Last Name:LEEDS
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 1:3754 COPPER PENNY LN
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95602-9276
Mailing Address - Country:US
Mailing Address - Phone:530-889-8659
Mailing Address - Fax:
Practice Address - Street 1:3111 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:CA
Practice Address - Zip Code:95603-2456
Practice Address - Country:US
Practice Address - Phone:530-885-5618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA043004207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A430040OtherMEDI-CAL
CA00A430040OtherMEDI-CAL
CAF12525Medicare UPIN
CA00A430040Medicare PIN