Provider Demographics
NPI:1497774046
Name:LEATHERS, STEPHEN DALE
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:DALE
Last Name:LEATHERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:STEPHEN
Other - Middle Name:D
Other - Last Name:LEATHERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 173862
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-3862
Mailing Address - Country:US
Mailing Address - Phone:303-306-7783
Mailing Address - Fax:303-306-7753
Practice Address - Street 1:1501 S POTOMAC ST
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-5411
Practice Address - Country:US
Practice Address - Phone:303-695-2628
Practice Address - Fax:303-306-7753
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2003-01485207P00000X
SC29303207P00000X
CODR0050115207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO32300051Medicaid
COP01394181OtherRAILROAD MEDICARE
CO32300051Medicaid
CO351656YL2GMedicare PIN