Provider Demographics
NPI:1508970211
Name:LEADER, LAWRENCE J (DO)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:J
Last Name:LEADER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-296-3399
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:415 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7246
Practice Address - Country:US
Practice Address - Phone:601-268-5800
Practice Address - Fax:601-261-3530
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14515207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115279Medicaid
MS640507572YROtherAMERICAN ADMIN GROUP
LA1779539Medicaid
MSP00249149OtherRAILROAD MEDICARE
MS00115279Medicaid
MS640507572YROtherAMERICAN ADMIN GROUP