Provider Demographics
NPI:1497747349
Name:LEATHERWOOD, MICHAEL A (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:LEATHERWOOD
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:PO BOX 249
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20604-0249
Mailing Address - Country:US
Mailing Address - Phone:301-645-6667
Mailing Address - Fax:301-870-9722
Practice Address - Street 1:12070 OLD LINE CTR
Practice Address - Street 2:SUITE 302
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-2513
Practice Address - Country:US
Practice Address - Phone:301-645-6667
Practice Address - Fax:301-870-9722
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0021031207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACN1724Medicare PIN
MD627AMedicare PIN
B69591Medicare UPIN