Provider Demographics
NPI:1508822263
Name:LEATHERWOOD, BRADLEY D (MD)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:D
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 1:1022 E 6TH 1/2 ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77009-7328
Mailing Address - Country:US
Mailing Address - Phone:713-614-3172
Mailing Address - Fax:281-888-5754
Practice Address - Street 1:1022 E 6TH 1/2 ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77009-7328
Practice Address - Country:US
Practice Address - Phone:713-614-3172
Practice Address - Fax:281-888-5754
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2012-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46454207L00000X
TXM3625207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L10517Medicare PIN
TXTXB111563Medicare PIN